CA DHCS 1737 2014-2025 free printable template
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State of California Health and Human Services Agency Department of Health Care Services MHP RE-CERTIFICATION of COUNTY-OWNED AND OPERATED PROVIDERS SELF-SURVEY FORM COUNTY INFORMATION County Submitting
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How to fill out recipient provider - dhcs
How to fill out CA DHCS 1737
01
Gather necessary documentation, including personal identification and income information.
02
Obtain the CA DHCS 1737 form from the California Department of Health Care Services website or your local office.
03
Fill in your personal details in the designated sections, such as name, address, and contact information.
04
Provide information regarding your household size and income in the appropriate sections.
05
Review the completed form for accuracy and completeness.
06
Sign and date the form at the bottom to certify that the information provided is true.
07
Submit the completed form via mail or in person to your local county office.
Who needs CA DHCS 1737?
01
Individuals seeking to receive Medi-Cal benefits or health coverage through the California Department of Health Care Services.
02
Low-income families or individuals who meet eligibility criteria for public health programs.
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What is CA DHCS 1737?
CA DHCS 1737 is a form used by the California Department of Health Care Services to report certain healthcare-related data and information.
Who is required to file CA DHCS 1737?
Providers of Medi-Cal services and other healthcare entities regulated by the California Department of Health Care Services are required to file CA DHCS 1737.
How to fill out CA DHCS 1737?
To fill out CA DHCS 1737, you need to provide accurate information about your services, patient data, and financial information as specified in the instructions provided with the form.
What is the purpose of CA DHCS 1737?
The purpose of CA DHCS 1737 is to facilitate data collection for monitoring and evaluating Medi-Cal services and ensuring compliance with state regulations.
What information must be reported on CA DHCS 1737?
Information reported on CA DHCS 1737 must include patient demographics, service types provided, claims data, and any other relevant healthcare service information as required by the form.
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