Get Ca Dhcs 9096 2011-2026

The California Department of Health Care Services (DHCS) 9096 form is designed for individual dentist or physician practices relocating within the same county. This guide will provide you with a step-by-step approach to filling out this important form online, ensuring clarity and accuracy throughout the process.

Follow the steps to complete the CA DHCS 9096 form efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your legal name as it appears on your tax identification documents in the appropriate field.
3. Fill in your National Provider Identifier (NPI) number in the designated field.
4. If your business has a different name than the legal name, enter it in the business name field.
5. Provide your primary business telephone number. Ensure that you do not use a beeper number, cell phone, or answering service.
6. Enter your new business address. Include the street name, number, room or suite number, city, county, state, and nine-digit ZIP code. Avoid using a post office box.
7. Indicate the pay-to address where you would like to receive payment, including all relevant details as outlined.
8. Specify your mailing address for general correspondence from Medi-Cal or Denti-Cal.
9. If applicable, enter any local business license or permit numbers and attach copies.
10. Provide your Clinical Laboratory Improvement Amendment (CLIA) certificate number and attach a legible copy.
11. Enter your state laboratory license or registration number, attaching relevant documentation.
12. Record your previous business address to establish your relocation details.
13. Attach your current Certificate of Comprehensive Liability Insurance to the application.
14. Print your name as the applicant. An original signature is required along with your city, state, and date.
15. Include your dental or medical license number and attach a copy.
16. Lastly, provide your driver’s license or state-issued identification number, attaching a legible copy.
17. Review all entries for completeness, ensuring no sections are left blank. If an item is not applicable, denote it by entering N/A.
18. Once satisfied with the form's completion, you can save changes, download, print, or share the form as needed.

Complete your CA DHCS 9096 form online today to ensure a smooth transition to your new practice location.