Get Ca Dhcs 6206 2013-2026

The CA DHCS 6206 form, also known as the Medi-Cal Medical Transportation Provider Application, is essential for individuals or organizations looking to enroll in the Medi-Cal program as a provider. This guide provides a clear and concise walkthrough for filling out the form online, ensuring all necessary steps are understood.

Follow the steps to complete the CA DHCS 6206 form online.

1. Use the ‘Get Form’ button to access the CA DHCS 6206 form and open it in the editing interface.
2. Begin by selecting the enrollment action you are requesting. Check all applicable boxes: 'New provider,' 'Change of business address,' 'Additional business address,' or 'Change of ownership.' Ensure to indicate the effective date where applicable.
3. Complete the Medi-Cal Application Fee section. Indicate if you are currently enrolled in Medicare or another state’s Medicaid/CHIP or if you have already paid the application fee.
4. Fill in your type of entity. Choose from the options: sole proprietor, corporation, partnership, limited liability company (LLC), government entity, or nonprofit corporation. Provide any required additional information based on your choice.
5. In the transportation section, check all relevant types of transportation services you will provide: emergency, nonemergency, wheelchair van, or litter van.
6. Enter the legal name and business name associated with your IRS registration. If applicable, provide your fictitious business name permit number.
7. Provide complete business contact information. Include physical, mailing, and pay-to addresses along with the primary business telephone number. Ensure this information is accurate and clearly formatted.
8. List your Taxpayer Identification Number (TIN) or provide the social security number if you are a sole proprietor not using a TIN. Attach the required IRS documentation.
9. Complete the hours of operation section indicating the days and hours your services will be available.
10. Indicate whether you have Workers’ Compensation insurance and provide necessary documentation if applicable.
11. Detail the geographic areas you will serve and attach any necessary business permits or licenses.
12. Fill in the ambulance, aircraft, or vehicle information as needed, and ensure to attach all required supporting documentation, such as licenses and certificates.
13. Provide the printed name, signature, gender, and driver’s license number of the individual completing the form. They must also specify their title, location, and the date of signing.
14. Include the contact person's name, email, and telephone number for any follow-up questions regarding the application.
15. Review the entire form for accuracy. Make any necessary corrections by carefully lining through mistakes, dating, and initialing changes in ink.
16. Save your completed form, and consider your options to download, print, or share it as required to submit to the Department of Health Care Services.

Start completing your CA DHCS 6206 form online today to ensure your application for the Medi-Cal program is processed smoothly.