Department of Health Care Services
SAFETY NET FINANCING DIVISION
GROUND EMERGENCY MEDICAL TRANSPORTATION
POINT OF CONTACT INFORMATION
Check all boxes that apply:
New Contact
Main Contact
Update Contact
Secondary Contact
Remove Contact
Additional Contact
GEMT Provider Legal Name:
GEMT Provider DBA Name:
GEMT Program Contact Name:
Title:
Address:
City: State: CA Zip:
Phone: Extension:
Fax: Email:
Fire Chief Name: Fire Chief’s Phone Number:
NPI #: DHCS Vendor #: GEMT
Please identify your program eligibility authority: City County City & County
Fire Protection District Healthcare District Indian Tribe State
Have acquired/merged with any other entity since January 30, 2010?
Yes No Date Acquired:
If so, please provide name(s) of acquitted entity:
New/Additional Contact Signature:
GEMT Program Coordinator Signature:
Print GEMT Coordinator Name: Date:
Return to: GEMT@dhcs.ca.gov
www.dhcs.ca.gov/provgovpart/Pages/gemt.aspx
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