Get Ca Dhcs 6216 2005

The CA DHCS 6216 form serves as an application for enrollment or continued enrollment as a rendering provider in the Medi-Cal program. This guide will provide you with clear and detailed instructions on how to complete this form online, ensuring a smooth process for your application. Follow the steps below to accurately fill out the CA DHCS 6216 form.

Follow the steps to complete the CA DHCS 6216 form online:

1. Click the ‘Get Form’ button to access the CA DHCS 6216 form and open it in the editor.
2. Begin by checking the boxes for the actions you request. Enter the date on which you are completing this application.
3. Select your provider type by checking the appropriate box that reflects the service you will render under the Medi-Cal program.
4. Provide the legal name as registered with the Internal Revenue Service (IRS).
5. Enter your date of birth and gender as prompted.
6. Optional: Enter your Social Security number, though it is not a mandatory field.
7. Provide your driver’s license or state-issued identification number, along with the state of issuance. Remember to attach a legible copy of the ID.
8. Enter your professional license number, its effective date, and expiration date. If you are a physician, list your specialty and indicate if you are board-certified or board-eligible.
9. Fill in your business address, ensuring you provide the complete physical address with no post office boxes or commercial addresses.
10. Enter your business telephone number, ensuring it is a primary number where you can be contacted.
11. Provide the name of a contact person regarding the application and include their telephone number and email address.
12. Enter the residence address of the individual listed in step 4.
13. Complete the disclosure information section, checking the appropriate boxes regarding convictions, liabilities, and previous participant status in Medi-Cal or other Medicaid programs if applicable.
14. If you need to report any suspensions or revoked licenses, check the relevant boxes and provide details as requested.
15. Sign and print your name in the designated section, entering the city, state, and date where you signed the form.
16. Finally, check that all required documents are attached, and do not leave any sections blank; ensure to enter 'N/A' where necessary.

Complete your CA DHCS 6216 form online today to ensure your enrollment as a Medi-Cal rendering provider.