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- Click ‘Get Form’ to open the Department Updates - DHCS - CA in the editor.
- Begin by entering your legal name as listed with the IRS in the designated field. Ensure accuracy to avoid processing delays.
- Provide your business name if it differs from your legal name. If using a fictitious business name, attach the necessary documentation.
- Fill in your primary business telephone number and ensure it is a valid contact for correspondence.
- Complete the business address section accurately, including street number, city, and ZIP code. Avoid using P.O. boxes unless specified.
- Indicate any enrollment actions requested by checking the appropriate boxes, such as 'New provider' or 'Change of business address'.
- Attach all required documents, including proof of insurance and NPI verification, ensuring they are legible and correctly formatted.
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