CA DHCS 6216 2015 free printable template
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State of CaliforniaHealth and Human Services AgencyDepartment of Health Care ServicesINSTRUCTIONS FOR COMPLETION OF THE
MEDICAL RENDERING PROVIDER APPLICATION/DISCLOSURE
STATEMENT/AGREEMENT FOR PHYSICIAN/ALLIED/DENTAL
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How to fill out medi-cal rendering provider applicationdisclosure
How to fill out CA DHCS 6216
01
Obtain the CA DHCS 6216 form from the official California Department of Health Care Services website or your local health office.
02
Fill in your personal information at the top of the form, including your name, address, and contact information.
03
Indicate your eligibility by selecting the appropriate program or service that applies to you.
04
Provide any required supporting documentation as specified in the form instructions.
05
Review the form for completeness and accuracy.
06
Sign and date the form where indicated.
07
Submit the completed form to the appropriate mailing address or hand it in at your local health office.
Who needs CA DHCS 6216?
01
Individuals applying for Medi-Cal or other assistance programs provided by the California Department of Health Care Services (DHCS).
02
Patients seeking reimbursement for certain health care services.
03
Providers submitting claims for services rendered to eligible beneficiaries.
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What is CA DHCS 6216?
CA DHCS 6216 is a form used by the California Department of Health Care Services to report and monitor certain health care data and services within California's Medi-Cal program.
Who is required to file CA DHCS 6216?
Entities participating in the Medi-Cal program, such as Medi-Cal providers, managed care plans, and other health care organizations are required to file CA DHCS 6216.
How to fill out CA DHCS 6216?
To fill out CA DHCS 6216, providers must provide specific information pertaining to their services, including patient details, service dates, and relevant financial data as instructed in the form's guidelines.
What is the purpose of CA DHCS 6216?
The purpose of CA DHCS 6216 is to ensure accurate tracking and reporting of health service utilization and to help the state monitor and improve the delivery of health care services in the Medi-Cal program.
What information must be reported on CA DHCS 6216?
The information that must be reported on CA DHCS 6216 includes patient identifiers, service codes, dates of service, billing amounts, and any other relevant data required by the California Department of Health Care Services.
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