"Point of Contact Information - Ground Emergency Medical Transportation" - California

Point of Contact Information - Ground Emergency Medical Transportation is a legal document that was released by the California Department of Health Care Services - a government authority operating within California.

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Department of Health Care Services
SAFETY NET FINANCING DIVISION
GROUND EMERGENCY MEDICAL TRANSPORTATION
POINT OF CONTACT INFORMATION
Check all boxes that apply:
New Contact
Main Contact
Update Contact
Secondary Contact
Remove Contact
Additional Contact
GEMT Provider Legal Name:
GEMT Provider DBA Name:
GEMT Program Contact Name:
Title:
Address:
City:
State: CA
Zip:
Phone:
Extension:
Fax:
Email:
Fire Chief Name:
Fire Chief’s Phone Number:
NPI #:
DHCS Vendor #: GEMT
Please identify your program eligibility authority:
City
County
City & County
Fire Protection District
Healthcare District
Indian Tribe
State
Have acquired/merged with any other entity since January 30, 2010?
Yes
No
Date Acquired:
If so, please provide name(s) of acquitted entity:
New/Additional Contact Signature:
GEMT Program Coordinator Signature:
Print GEMT Coordinator Name:
Date:
Return to:
GEMT@dhcs.ca.gov
www.dhcs.ca.gov/provgovpart/Pages/gemt.aspx
Department of Health Care Services
SAFETY NET FINANCING DIVISION
GROUND EMERGENCY MEDICAL TRANSPORTATION
POINT OF CONTACT INFORMATION
Check all boxes that apply:
New Contact
Main Contact
Update Contact
Secondary Contact
Remove Contact
Additional Contact
GEMT Provider Legal Name:
GEMT Provider DBA Name:
GEMT Program Contact Name:
Title:
Address:
City:
State: CA
Zip:
Phone:
Extension:
Fax:
Email:
Fire Chief Name:
Fire Chief’s Phone Number:
NPI #:
DHCS Vendor #: GEMT
Please identify your program eligibility authority:
City
County
City & County
Fire Protection District
Healthcare District
Indian Tribe
State
Have acquired/merged with any other entity since January 30, 2010?
Yes
No
Date Acquired:
If so, please provide name(s) of acquitted entity:
New/Additional Contact Signature:
GEMT Program Coordinator Signature:
Print GEMT Coordinator Name:
Date:
Return to:
GEMT@dhcs.ca.gov
www.dhcs.ca.gov/provgovpart/Pages/gemt.aspx