Get Dhcs 6170 Form

Filling out the Dhcs 6170 Form online is a straightforward process that enables users to provide necessary information for re-certification of county-owned and operated providers. This guide will walk you through each section of the form to ensure you understand how to complete it accurately and efficiently.

Follow the steps to successfully complete the Dhcs 6170 Form online.

1. Press the ‘Get Form’ button to access the Dhcs 6170 Form and open it in a digital format.
2. In the county information section, fill in the name of the county submitting the form, the county code, and the National Provider Identifier (NPI) number.
3. Indicate whether the provider is activating any modes or changing names by selecting 'Yes' or 'No.' If 'Yes,' complete the necessary items on page 2.
4. In the provider information section, input the provider's name, address, provider number, city, and zip code.
5. Under services provided, check all applicable service types that the provider offers, including outpatient and residential options.
6. Carefully answer each evaluation criterion question, selecting 'Yes,' 'No,' or 'N/A' as appropriate. Ensure that supporting documentation is attached where required.
7. Provide the date of fire clearance, recertification date, and any relevant activation dates.
8. Complete the certification statement by signing and printing the name and title of the person completing the form, as well as the mental health director or designee.
9. Once all fields are completed, save changes, and download the form. You can also print or share it as needed.

To ensure compliance and avoid delays, complete your Dhcs 6170 Form online today!