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Get CA DHCS 6216 2015-2024

D/DENTAL PROVIDERS DO NOT USE staples on this form or on any attachments. DO NOT USE correction tape, white out, or highlighter pen or ink of a similar type on this form. If you must make corrections, please line through, date and initial in ink. DO NOT LEAVE any question, boxes, lines, etc. blank. Enter N/A if not applicable to you. This form is part of an application for enrollment or continued enrollment as a rendering provider in the Medi-Cal program. Applicants and providers must also provi.

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