Get Ca Dhcs 6204 2013

The CA DHCS 6204 form serves as the Medi-Cal provider enrollment application for individuals and businesses seeking to participate in California's Medi-Cal program. Completing this form accurately is crucial to avoid delays in the enrollment process.

Follow the steps to successfully fill out the CA DHCS 6204 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Review the instructions carefully. Ensure you understand the requirements and gather all necessary information before proceeding.
3. Fill in the enrollment action requested, checking all relevant boxes for your application, such as ‘New provider’ or ‘Change of business address’, and enter the date of completion.
4. Provide your legal name and business name as listed with the IRS. If applicable, include your fictitious business name.
5. Enter the business address, ensuring to include all required details such as street number, city, and ZIP code.
6. If applicable, indicate whether the business address is a licensed health facility, and if so, check the relevant box.
7. Complete the sections detailing your contact information, including business telephone number, pay-to address, and mailing address.
8. List your license number along with the effective and expiration dates, attaching a legible copy of the relevant document.
9. Provide your National Provider Identifier (NPI) as required, attaching confirmation from the CMS/NPPES for verification.
10. Fill out the Taxpayer Identification Number (TIN) and any additional details for Nurse Practitioners, if applicable.
11. Detail your proof of liability and professional liability insurance, including policy numbers and insurance company contact information.
12. Ensure you sign the application legibly, entering the city, date, and position of the signer.
13. Review the completed form for accuracy, ensuring that all fields have been filled out and no questions are left blank, entering N/A as needed.
14. Finally, save your changes, download a copy of the form, and/or prepare it for printing or sharing as required.

Complete your CA DHCS 6204 application online today for successful enrollment in the Medi-Cal program.