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Certain Paper Enrollment Applications Removed from the Medi-Cal Website

March 5, 2019

As specified in a previous Provider Enrollment Division (PED) provider bulletin published January 4, 2019, on November 18, 2016, the Department of Health Care Services (DHCS) instituted a web-based Medi-Cal provider enrollment system entitled Provider Application and Validation for Enrollment (PAVE) 2.0 and on September 4, 2018, instituted PAVE 3.0. PAVE provides a new mode of submitting provider enrollment applications and required documentation to DHCS by means of an electronic form, the Medi-Cal Provider e-Form Application (e-Form).

With the implementation of the PAVE provider portal, the following paper enrollment applications are removed from the Medi-Cal website:

  • Crossover Only Provider Form (MC 0804)
  • Drug Medi-Cal Provider Agreement (DHCS 6009)
  • Drug Medi-Cal Substance Use Disorder Clinic Application (DHCS 6001)
  • Medi-Cal Change Of Location Form For Individual Physician Or Individual Dentist Practices Relocating Within The Same County (DHCS 9096)
  • Medi-Cal Clinical Medical Laboratory Application (DHCS 6204)
  • Medi-Cal Clinic-Based Certified Nurse Midwife Application (DHCS 6204)
  • Medi-Cal Director/Licensed SUD Treatment Professional/SUD Nonphysician Medical Practitioner (DHCS 6010)
  • Medi-Cal Disclosure Statement (DHCS 6207)
  • Medi-Cal Durable Medical Equipment Provider Application (DHCS 6201)
  • Medi-Cal Group Designation of Delegated Officials Form (DHCS 5263)
  • Medi-Cal Hospital-Based Physician Application/Disclosure Statement/Agreement (DHCS 9095)
  • Medi-Cal Non-physician Medical Practitioner and Licensed Midwife Application (DHCS 6248)
  • Medi-Cal Ordering/Referring/Prescribing Provider Application/Agreement/Disclosure Statement For Physician and Non-physician Practitioners (DHCS 6219)
  • Medi-Cal Orthotics and Prosthetics Provider Application (DHCS 6202)
  • Medi-Cal Pharmacy Provider Application (DHCS 6205)
  • Medi-Cal Physician Application/Agreement (DHCS 6210)
  • Medi-Cal Provider Agreement (DHCS 6208)
  • Medi-Cal Provider Application (DHCS 6204)
  • Medi-Cal Provider Group Application (DHCS 6203)
  • Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers (DHCS 6216)
  • Medi-Cal Rendering Provider/Group Affiliation/Disaffiliation Form (DHCS 4029)
  • Out-of-State Provider Express Enrollment (MC 4603)

The Provider Enrollment page of the Medi-Cal website is updated for these and other changes. Updated manual pages will be released in a future Medi-Cal Update.



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