Get Dhcs 6216

The Dhcs 6216 form is essential for the Medi-Cal rendering provider application process. This guide provides straightforward, step-by-step instructions to assist users in completing the form accurately and efficiently, ensuring a smooth submission experience.

Follow the steps to complete the Dhcs 6216 form online.

1. Press the 'Get Form' button to access the Dhcs 6216 form and open it in your editing tool.
2. Begin by filling in your National Provider Identifier (NPI). If you do not have one, enter 'atypical' in the NPI field.
3. Provide personal details such as the legal name, date of birth, and gender of the individual listed as the applicant.
4. Enter the residence and mailing addresses. Ensure that all addresses are complete, including city, state, and ZIP code.
5. Fill in the social security number. This information is mandatory for processing your application.
6. Provide the driver’s license or state-issued identification number. Attach a legible copy of this identification.
7. Enter your health care license or certificate details, including the number, effective date, expiration date, and specialty if applicable. Attach a copy of the license.
8. Document the business address and telephone number. Only provide a valid location and contact number for your practice.
9. List the contact person’s name and their contact details, ensuring that this person is available for any inquiries regarding the application.
10. Fill out the proof of professional liability insurance, including all required details and attachments of the insurance certificate.
11. Address the disclosure information questions as prompted, checking the appropriate boxes and providing additional details if necessary.
12. Sign the application form with your original signature, including the date and location of signing.
13. Review the completed form for accuracy, ensuring all fields are filled out as required. Do not leave any blank fields.
14. Finally, save the changes made to the form, and choose whether to download, print, or share the completed application.

Complete your Dhcs 6216 form online today for successful Medi-Cal provider enrollment.