Get Ca Dhcs 4502 2008-2026

The CA DHCS 4502 is a critical document for laboratory providers seeking to participate in the California Child Health and Disability Prevention (CHDP) Program. This guide provides comprehensive step-by-step instructions on how to accurately complete the form online, ensuring a smooth application process.

Follow the steps to fill out the CA DHCS 4502 form online.

1. Click 'Get Form' button to obtain the form and open it in the designated editor.
2. Carefully review the attached instructions provided with the form for guidance on required information.
3. In the section titled 'Application for participation as,' select the appropriate type of laboratory by checking the corresponding box.
4. Enter the legal name of the laboratory in the designated field. This should be the name listed with the IRS.
5. Provide all active provider numbers associated with the laboratory, ensuring they match the business address stated in the form.
6. Fill in the state laboratory license or registration number, as required.
7. If your business name differs from the legal name, input that in the 'Business name' field and attach the Fictitious Business Name Statement/Permit if applicable.
8. Complete the business address with the primary location where services are provided, avoiding post office boxes.
9. Include the primary business telephone number, ensuring it is not a personal or temporary number.
10. Enter the fax number if applicable, followed by the email address for electronic communications.
11. Provide the pay-to name for payment processing and corresponding pay-to address for billing purposes.
12. Select the type of business by checking the appropriate box, and provide names of the principal owners.
13. List the names and addresses of the director(s) of the laboratory in the specified fields.
14. Enter the CLIA certificate number and attach a copy of the certificate.
15. Specify the expiration date of the CLIA certificate in the designated field.
16. Indicate the number of testing sites associated with the CLIA certificate provided.
17. Mark whether the facility is located within a licensed acute care hospital.
18. Print the name of the Laboratory Director, then secure the director's signature in blue ink only and date the application.
19. Print the name of the Owner, obtain the owner's signature in blue ink, and include the date.
20. Review the completed form for accuracy, ensuring all required information is included.
21. Once all fields are complete, save your changes, then choose to download, print, or share the form as necessary.

Complete your CA DHCS 4502 form online today to ensure your application process is efficient and straightforward.