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State of California Health and Human Services AgencyDepartment of Health Care Services Counselor & Medication Assisted Treatment Section, MS 2603 PO Box 997413 Sacramento, CA 958997413AFFILIATED AND
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How to fill out dhcs 5134 affiliated and
How to fill out dhcs 5134 affiliated and
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To fill out DHCS 5134 Affiliated form, follow these steps:
02
Start by downloading the DHCS 5134 Affiliated form from the official website or obtain a copy from your local DHCS office.
03
Begin by providing your personal information in the designated sections of the form. This may include your name, address, phone number, and social security number.
04
If you are filling out the form on behalf of an organization or agency, enter the name of the organization and the contact information.
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Proceed to the section where you will need to provide information about your affiliated activities or services. This may include details about the programs, services, or resources you offer.
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Make sure to provide accurate and complete information for each affiliated activity or service.
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If you have additional affiliated activities or services, use additional pages or attach separate sheets as necessary.
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Review the completed form to ensure all the information provided is correct and legible.
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Sign and date the form in the designated sections.
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Make a copy of the filled-out form for your records before submitting it to the appropriate DHCS office.
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Submit the completed DHCS 5134 Affiliated form by mail or in person to the appropriate DHCS office as instructed.
Who needs dhcs 5134 affiliated and?
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DHCS 5134 Affiliated form is typically required by organizations and agencies that offer programs, services, or resources that are affiliated with the California Department of Health Care Services (DHCS).
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These organizations may need to fill out the DHCS 5134 Affiliated form to provide necessary information about their affiliated activities or services.
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Examples of organizations that may need to fill out this form include healthcare providers, community clinics, social service agencies, and nonprofit organizations.
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It is advisable to consult with the DHCS or refer to specific guidelines to determine if your organization needs to fill out the DHCS 5134 Affiliated form.
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What is dhcs 5134 affiliated and?
dhcs 5134 affiliated and is a form used by the California Department of Health Care Services (DHCS) to collect information about entities affiliated with Medi-Cal providers.
Who is required to file dhcs 5134 affiliated and?
Entities affiliated with Medi-Cal providers are required to file dhcs 5134 affiliated and.
How to fill out dhcs 5134 affiliated and?
DHCS 5134 affiliated and can be filled out online or submitted through mail. It requires detailed information about the affiliated entities.
What is the purpose of dhcs 5134 affiliated and?
The purpose of dhcs 5134 affiliated and is to ensure transparency and accountability in the Medi-Cal program by tracking affiliations between different entities.
What information must be reported on dhcs 5134 affiliated and?
Information such as legal name, tax ID number, address, ownership percentage, and relationships with other entities must be reported on dhcs 5134 affiliated and.
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