Get Ca Dhcs 5014 2016-2026

The CA DHCS 5014 form is an essential document used for the initial application coversheet for narcotic treatment programs in California. This guide provides a comprehensive overview of how to complete the form online, ensuring that all necessary information is accurately submitted.

Follow the steps to fill out the CA DHCS 5014 form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Complete Section A by selecting the type of application you are submitting, marking the appropriate box for Narcotic Treatment Program (NTP), Detoxification Treatment, or other relevant categories.
3. Proceed to Section B to provide your applicant information. Enter your license number if applicable, your National Provider Identifier (NPI), the name of your legal entity, and select the tax status of your business.
4. Input the facility's street address, city, county, and zip code in the designated fields. Ensure this information is accurate, as it will be verified.
5. If your mailing address differs from your facility's address, complete the mailing address section similarly, including the city, county, and zip code.
6. Fill in the contact details, including the telephone number and fax number associated with the program.
7. Provide the names of the program sponsor, program director, and medical director along with the proposed capacity for the program.
8. If applying as a Medication Unit (MU) or Office-Based Narcotic Treatment Network (OBNTN), complete Section C with the relevant details.
9. In Section D, the program sponsor needs to print their name, sign the form, and date it to verify the accuracy of the submitted information.
10. After completing all sections, review the form for any inaccuracies or omissions. Once confirmed, you can save changes, download, print, or share the completed form as needed.

Start your application process by completing the CA DHCS 5014 form online today.