Understanding and completing the California State Department of Health Care Services (DHCS) Form 0005 can be overwhelming, especially for new healthcare providers. It's an important form related to one's enrollment process with DHCS and it requires submission of all necessary information associated with attesting their practice in Medi-Cal, a health care program available for people who qualify based on income. In this blog post, we'll provide you with everything you need to know about Form DHCS 0005 including why it is required, what it contains, and how to submit your completed application. By following these steps outlined here, healthcare providers will learn all the critical details so they can avoid costly delays in their enrollment process!
| Question | Answer |
|---|---|
| Form Name | Form Dhcs 0005 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | issuing, dhcs0005, Citizenship, California |
State of California – Health and Human Services Agency |
Department of Health Care Services |
Receipt of Citizenship or Identity Documents
Instructions to County/DSH/FQHC Staff: When you receive citizenship and/or identity document(s) for an applicant or beneficiary, you must fill out this form.
Citizenship/Identity document for Applicant or Beneficiary:
______________________________________________________________Date of birth:_______________
FirstMiddleLast
Address: ________________________________________________________________________________
STREETCityStateZip Code
Name of parent if Applicant or Beneficiary is a child: ______________________________________________
First |
Middle |
Last |
Applicant or Beneficiary BIC/CIN: ________________________________ |
|
|
Name of the citizenship/identity document you saw:
The document you saw was (check one):
An original (not a photocopy or a notarized copy) A copy that was certified by the issuing agency
This document was received (check one): By mail
In person (from the applicant or beneficiary) Name:_____________________________
In person (from a guardian, authorized representative, or caretaker relative) (Name and relationship to applicant or beneficiary)
__________________________________
Name of the citizenship/identity document you saw:
The document you saw was (check one):
An original (not a photocopy or a notarized copy) A copy that was certified by the issuing agency
This document was received (check one): By mail
In person (from the applicant or beneficiary) Name: _____________________________
In person (from a guardian, authorized representative, or caretaker relative) (Name and relationship to applicant or beneficiary)
___________________________________
Make a photocopy of the citizenship and/or identity document received from the applicant or beneficiary, return the original document(s) to the bearer and provide a copy of the signed receipt to the bearer. Once the document is received by the eligibility worker, the county social services office will notify the applicant or beneficiary of this receipt if the document(s) provided are acceptable. DSH/FQHC staff must send this receipt and copies of the document(s) to the appropriate county social services office.
County/DSH/FQHC Staff reads and signs below.
I declare under penalty of perjury under the laws of the State of California that the information above is true and correct.
__________________________________________________________ |
Date: ______________________ |
|||||||
Signature of County/DSH/FQHC Staff |
|
|
|
|
|
|
||
Name of County/DSH/FQHC Staff (print): |
|
|
|
|
|
|
||
|
|
|
|
First |
Middle |
Last |
||
Information: |
|
|
|
|
|
|
||
|
|
Name of agency |
County |
Telephone number |
||||
|
|
|
|
|
|
|
|
|
|
|
|
County fills out this box |
|
|
|
||
Case No: |
|
Case Name: |
|
|
|
|||
|
|
|
|
|
|
|
|
|
DHCS 0005 (02/08) |
Page 1 of 1 |