Fillable Form 6252 Electronic Funds Transfer (Eft) Enrolled User Enrollment Form (Page 2 of 2) in pdf

Instructions:

Section I - General Information (All information is required, except F.)

A. Program Name: Select a program from the drop down menu for the type of payment that you will

make.

B. DHCS Account:

 For Beneficiaries, enter your Client Index Number (CIN), and DHCS will provide you with the

complete DHCS Account to use.

 For Law Offices, this will be assigned by DHCS. Leave this field blank.

 For Providers, enter your National Provider Identifier (NPI) or Client Index Number (CIN), and

DHCS will provide you with the complete DHCS Account to use.

C. Beneficiary/ Provider/ Attorney/ Case Name: Enter the complete Medi-Cal Beneficiary or Provider

Name as shown on DHCS invoice or correspondence. For Attorneys, enter your business name. For

Estate Recovery, enter the Estate or Case Name.

D. Mailing Address: Enter your mailing address where DHCS correspondence and forms should be

sent. For verification purposes, this information should match your records with the Medi-Cal program.

E. Email Address: Enter your email address and re-enter to make sure that it is correct.

F. Payment Contact Person: If different from the Beneficiary Name, enter name of the authorized

personal representative of the beneficiary, or the name of the contact person for a Provider, Business,

or Estate. This is required for Providers and Law Offices.

 If you are an authorized personal representative for a beneficiary (e.g. legal guardian, conservator,

etc.), please provide proof of authority to sign on behalf of the beneficiary (e.g. letters of

conservancy, court order, etc.)

G. Phone Number: Enter the phone number that DHCS can contact you regarding your EFT account.

Section II - Authorization – This section must be completed.

A. Signature: The beneficiary, attorney, or the provider’s contact person must sign the form to indicate

participation in the EFT Enrolled User option and agreement with the terms and conditions.

B. Date: Enter the date the form is signed.

Send the completed enrollment form by mailing to:

Department of Health Care Services

TPLRD ASU EFT Admin, MS 4718

P.O. Box 997425

Sacramento, CA 95899-7425

By enrolling in the Enrolled User option, payments are not automatically deducted from your bank

account. Enrolled Users are responsible for logging in and scheduling payments to DHCS.

Allow up to 5 business days for processing. DHCS will email you a security code and mail you a letter

confirming your DHCS Account after your enrollment has been processed.

Enrolled User option is recommended for payers that need to make monthly payments and want to view

payment history. It is also recommended for payers such as attorneys or providers who may need to

make payments for multiple accounts/cases.

For help in completing this form and for detailed information regarding EFT, please refer to the documents

under Quick Reference Links located at

DHCS 6252 (Rev 06/16)

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Form 6252 Electronic Funds Transfer (Eft) Enrolled User Enrollment Form Page 2