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Dhcs 6216-2026
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- Click ‘Get Form’ to open the DHCS 6216 in the editor.
- Begin by entering your legal name as listed with the IRS in the designated field.
- Provide your date of birth and gender in the respective fields.
- Fill in your residence address, ensuring all details are accurate, including city and ZIP code.
- Enter your social security number; this field is mandatory for processing.
- Input your driver’s license or state-issued ID number, attaching a legible copy as required.
- Complete the professional license section by providing your license number and effective dates, along with any specialties if applicable.
- In the disclosure section, answer all questions truthfully regarding any past convictions or disciplinary actions.
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Related links
This form is an application for enrollment or continued enrollment as a rendering provider in the Medi-Cal program.
Form DHCS 6216 NPI. Complete applications can take up to 6 months for processing. Fax: 415-885-7445 2001