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PE for Pregnant Women Web Page Revised and New MC 311 Form Posted

March 30, 2017

Effective March 30, 2017, the Qualified Provider Application and Agreement for Participation in the Presumptive Eligibility for Pregnant Women (PE4PW) Program (MC 311) form has been updated on the Presumptive Eligibility for Pregnant Women Web page of the Medi-Cal website. This form is completed by providers applying to become PE4PW Qualified Providers or once enrolled, when requesting to add to their list of PE4PW clinic(s).

Instructions on completing the form are included with the MC 311 (version 12/16). Providers should review the provider requirements, submission checklist and notification overview when completing the form.

Note:

Providers will submit the form to Telephone Service Center using the address provided on the form. PE4PW providers are encouraged to review the PE4PW Web page’s Frequently Asked Questions (FAQs) and to visit the NewsFlash area of the Medi-Cal website for articles and materials related to the PE4PW program.

The PE4PW Web page has three new headings. “Application Forms” has changed to “Paper Process Forms (usable until 9/30/17).” The new MC 311 form is posted under the new “Qualified Provider Enrollment Form” heading. Lastly, a “User Guide” heading has been added to accommodate the new Presumptive Eligibility for Pregnant Women (PE4PW) Application Web Portal User Guide.