Get Ca Dhcs 6216 2015-2026

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.

1. Press the ‘Get Form’ button to access the CA DHCS 6216 form and open it in your selected editor.
2. Indicate the action you are requesting by checking all applicable boxes at the top of the form, and enter the current date.
3. 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.
4. Fill in your legal name as registered with the IRS, your date of birth, and select your gender.
5. Enter your residence address, including street number and name, city, state, and nine-digit ZIP code.
6. Indicate your mailing address if different from your residence address.
7. Input your social security number, as this field is mandatory.
8. Provide your driver's license or state-issued identification number and the state of issuance, and attach a legible copy.
9. 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.
10. Complete your business address and ensure to provide your business telephone number. The number must be a primary business line.
11. Identify a contact person and provide their name, telephone number, and email address for correspondence purposes.
12. If joining a group, enter the Provider Number (NPI or Denti-Cal Provider Number) of the group.
13. 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.
14. 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.
15. Acknowledge and sign the provider agreement, providing your printed legal name, original signature, city, state, and date of execution.
16. 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.