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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How to fill out the CA DHCS 6216 online
The CA DHCS 6216 form is essential for professionals seeking enrollment or continued enrollment as rendering providers in the Medi-Cal program. This guide provides detailed, step-by-step instructions on how to complete the form accurately and efficiently online.
Follow the steps to successfully complete the CA DHCS 6216 online form.
- Press the ‘Get Form’ button to access the CA DHCS 6216 form and open it in your selected editor.
- Indicate the action you are requesting by checking all applicable boxes at the top of the form, and enter the current date.
- Provide your National Provider Identifier (NPI), ensuring that if you have multiple NPIs, you only enter the one you will use for enrollment as a provider.
- Fill in your legal name as registered with the IRS, your date of birth, and select your gender.
- Enter your residence address, including street number and name, city, state, and nine-digit ZIP code.
- Indicate your mailing address if different from your residence address.
- Input your social security number, as this field is mandatory.
- Provide your driver's license or state-issued identification number and the state of issuance, and attach a legible copy.
- Enter your professional license, certificate, or permit number and its effective and expiration dates, if applicable. Also, indicate your specialty if you are a physician or dentist.
- Complete your business address and ensure to provide your business telephone number. The number must be a primary business line.
- Identify a contact person and provide their name, telephone number, and email address for correspondence purposes.
- If joining a group, enter the Provider Number (NPI or Denti-Cal Provider Number) of the group.
- Complete the section regarding proof of professional liability insurance, including details like insurance provider, policy number, and contact information for your insurance agent. Attach a copy of your certificate of insurance.
- Respond to the disclosure information questions about convictions, previous participation in Medicaid programs, and any licensing issues, making sure to provide supporting documents as necessary.
- Acknowledge and sign the provider agreement, providing your printed legal name, original signature, city, state, and date of execution.
- Attach any required documents, such as copies of your ID, license, insurance certificate, and relevant confirmations, before submission.
Complete the CA DHCS 6216 form online to facilitate your enrollment in the Medi-Cal program.
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How do I contact State of California Benefits Identification Card?
Telephone Service Center: (800) 541-5555....Beneficiary questions on: Medi-Cal Eligibility. Benefits. Benefits Identification Card.
Can I download my 1095 B online?
If you are filing taxes for an individual mandate state and do not have a copy of your 1095B, you may download one immediately from your member website or request one by calling the number on your ID card or other member materials.
Can I print my Medi-Cal card online?
Click the print icon in the upper left hand corner of the PDF to print. You can print the ID card using your own printer and then use it at your next doctor's appointment.
What address do I use for Medi-Cal?
Here is more information on how to: Apply for Medi-Cal, get a Medi-Cal Application, or Find Out if you Qualify....Medi-Cal Contacts. GENERAL PUBLICPHONE / EMAILMedi-Cal Eligibility P.O. Box 997417, MS 4607 Sacramento, CA 95899-7417(916) 552-920014 more rows • Sep 2, 2022
How do I get a copy of my 1095 A form online?
How to find your 1095-A online Log in to your HealthCare.gov account. Under "Your Existing Applications," select your 2022 application — not your 2023 application. Select “Tax Forms” from the menu on the left. Download all 1095-As shown on the screen.
How much is provider app fee DHCS payment?
Application Fees This fee amount is established by the Centers for Medicare & Medicaid Services for each calendar year and the new $688.00 amount is required with any applicable enrollment application submitted on or after January 1, 2023 and on or before December 31, 2023.
How do I get proof of Medi-Cal coverage?
You will get a Form 1095-B for your Medi-Cal coverage from DHCS and you will also get a Form 1095‑A from Covered California. Each form will show the months of coverage that met the requirement for MEC for any months of coverage you got from either Medi‑Cal or Covered California.
How do I check my Medi-Cal coverage online?
Where Can I Access My Medi-Cal Member Services? You can access your member services online through your plan's website and the Covered California website. Each service manages different aspects of your coverage. Also, your local county office will take care of specific parts of your Medi-Cal membership.
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