CA DHCS 6204 2013 free printable template
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State of California Health and Human Services Agency Department of Health Care Services EDMUND G. BROWN JR. GOVERNOR TOBY DOUGLAS DIRECTOR Dear Applicant: Thank you for your recent inquiry regarding
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How to fill out CA DHCS 6204
01
Begin by gathering all necessary personal and financial information.
02
Fill in the applicant's name and contact details at the top of the form.
03
Provide information regarding the applicant's income, including any sources of revenue.
04
Complete the section regarding household members, listing all individuals who live with the applicant.
05
Clearly indicate any assets or properties owned by the applicant.
06
Review eligibility criteria and ensure all required documentation is attached.
07
Sign and date the form at the bottom to certify that the provided information is accurate.
Who needs CA DHCS 6204?
01
CA DHCS 6204 is needed by individuals applying for Medi-Cal benefits or seeking to renew their eligibility for these health services in California.
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What is CA DHCS 6204?
CA DHCS 6204 is a form used by the California Department of Health Care Services (DHCS) for reporting and reconciling Medi-Cal Managed Care enrollment information.
Who is required to file CA DHCS 6204?
Providers and managed care organizations that are involved in the Medi-Cal program are required to file CA DHCS 6204.
How to fill out CA DHCS 6204?
To fill out CA DHCS 6204, enter the required enrollment information, such as member demographics, enrollment dates, and service plans, ensuring accuracy and completeness.
What is the purpose of CA DHCS 6204?
The purpose of CA DHCS 6204 is to maintain accurate records of member enrollment in Medi-Cal Managed Care plans and ensure compliance with state regulations.
What information must be reported on CA DHCS 6204?
CA DHCS 6204 must report member identification details, enrollment and disenrollment dates, service delivery information, and any related adjustments.
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