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Skilled Nursing Facility Quality Assurance Fee (FY09) Payment Invoice for August 1, 2009, to August 31, 2009, Department of Health Care Services Accounting Section/Cashiers Unit Mail Stop 1101 1501
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What is dhcs 9116 form?
DHCS 9116 form is a document used by the California Department of Health Care Services (DHCS) to collect information about Medi-Cal beneficiaries who receive non-emergency medical transportation services.
Who is required to file dhcs 9116 form?
The medical providers who offer non-emergency medical transportation services to Medi-Cal beneficiaries are required to file the DHCS 9116 form.
How to fill out dhcs 9116 form?
The DHCS 9116 form should be filled out with accurate information about the Medi-Cal beneficiary, the medical transportation provider, and the services provided. The form includes sections for personal information, trip details, and certification.
What is the purpose of dhcs 9116 form?
The purpose of the DHCS 9116 form is to collect data on non-emergency medical transportation services provided to Medi-Cal beneficiaries. This information is used for program evaluation, planning, and monitoring purposes.
What information must be reported on dhcs 9116 form?
The DHCS 9116 form requires reporting of information such as the patient's name, Medicaid ID, dates of service, origin and destination of the trip, type of transportation used, and any special needs or accommodations provided.
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