Form DHCS6216 Medi-Cal Rendering Provider Application / Disclosure Statement / Agreement for Physician / Allied / Dental Providers - California

Form DHCS6216 Medi-Cal Rendering Provider Application / Disclosure Statement / Agreement for Physician / Allied / Dental Providers - California

What Is Form DHCS6216?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is the DHCS6216 form?
A: The DHCS6216 form is the Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers in California.

Q: Who should use the DHCS6216 form?
A: Physicians, allied health professionals, and dental providers in California who wish to join the Medi-Cal program should use the DHCS6216 form.

Q: What is the purpose of the DHCS6216 form?
A: The DHCS6216 form is used to apply for enrollment as a rendering provider in the Medi-Cal program. It also serves as a disclosure statement and agreement.

Q: What information is required in the DHCS6216 form?
A: The DHCS6216 form requires information such as personal details, professional credentials, employment history, billing information, and disclosure of any criminal convictions or disciplinary actions.

Q: How long does it take to process the DHCS6216 form?
A: The processing time for the DHCS6216 form can vary, but it generally takes several weeks to complete the enrollment process and receive a provider number.

Q: Is there a fee for submitting the DHCS6216 form?
A: There is no fee for submitting the DHCS6216 form, but there may be fees associated with other parts of the Medi-Cal enrollment process.

Q: What happens after I submit the DHCS6216 form?
A: After submitting the DHCS6216 form, the DHCS Provider Enrollment Division will review the application, process the request, and notify the provider of their enrollment status.

Q: Can I make changes to my information after submitting the DHCS6216 form?
A: Yes, you can make changes to your information after submitting the DHCS6216 form by submitting a new application or contacting the DHCS Provider Enrollment Division.

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Form Details:

  • Released on September 1, 2020;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form DHCS6216 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

Download Form DHCS6216 Medi-Cal Rendering Provider Application / Disclosure Statement / Agreement for Physician / Allied / Dental Providers - California

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  • Form DHCS6216 Medi-Cal Rendering Provider Application / Disclosure Statement / Agreement for Physician / Allied / Dental Providers - California, Page 1
  • Form DHCS6216 Medi-Cal Rendering Provider Application / Disclosure Statement / Agreement for Physician / Allied / Dental Providers - California, Page 2
  • Form DHCS6216 Medi-Cal Rendering Provider Application / Disclosure Statement / Agreement for Physician / Allied / Dental Providers - California, Page 3
  • Form DHCS6216 Medi-Cal Rendering Provider Application / Disclosure Statement / Agreement for Physician / Allied / Dental Providers - California, Page 4
  • Form DHCS6216 Medi-Cal Rendering Provider Application / Disclosure Statement / Agreement for Physician / Allied / Dental Providers - California, Page 5
  • Form DHCS6216 Medi-Cal Rendering Provider Application / Disclosure Statement / Agreement for Physician / Allied / Dental Providers - California, Page 6
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