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Provider Enrollment

Thank you for your interest in becoming a provider in the Medi-Cal program and welcome to the Medi-Cal Provider Enrollment page. This page contains information for fee-for-service healthcare providers who wish to apply for enrollment in the Medi-Cal program. This page is updated in conjunction with the Department of Health Care Services (DHCS) Provider Enrollment Division (PED) page. PED is responsible for the enrollment and re-enrollment of fee-for-service healthcare service providers into the Medi-Cal program.

For current application fee information, please see the Current Application Fee document on the DHCS website. The Centers for Medicare & Medicaid Services has announced a change in the provider Application Fee for Calendar Year 2014.

This Web page can assist you in the enrollment or re-enrollment process and is organized into the following sections:


Statutes, Regulations and Provider Bulletins
The criteria for enrollment as a provider in the Medi-Cal program are described in Title 22 of the California Code of Regulations (CCR). Senate Bill (SB) 857 (statutes of 2003), effective January 1, 2004, revised the responsibilities of providers and provider applicants in the Medi-Cal program. Links to documents describing statutes and regulations are as follows:


Application Forms by Form Name and Number
A complete application package includes the application, provider agreement, disclosure statement and all required attachments as stated on the forms. Please read and follow all instructions on each form carefully. Incomplete application packages will be returned and will delay your enrollment in the Medi-Cal program. Only current forms will be accepted as part of the complete application package. The most current revision of each application form is listed below.

Based on the services you provide, select the appropriate enrollment form(s) from the list below. The forms are in Portable Document Format (PDF) and are online-fillable. You may also print the form(s) and complete them using a pen. To assure you have access to all of the form features, please use Adobe Acrobat Reader version 7 (or above). The most current version of the free Adobe Acrobat Reader can be obtained by clicking here.

Form Name Form Number, Revised Date Note
Medi-Cal Ordering/Referring/Prescribing Provider Application/ Agreement/Disclosure Statement For Physician and Non-physician Practitioners DHCS 6219, New 1/13  
Medi-Cal Provider Agreement DHCS 6208, Revised 11/11 Required for all provider applicants unless one of the following is used:
  • Medi-Cal Physician Application/Agreement (DHCS 6210)
  • Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied Providers (DHCS 6216)
  • Medi-Cal Change of Location Form for Individual Physician Practices Relocating Within the Same County (DHCS 9096)
  • Medi-Cal Hospital-Based Physician Application/Disclosure Statement/Agreement (DHCS 9095)
Medi-Cal Provider Agreement (Institutional Provider) DHCS 9098, New 6/10 Required for all institutional applicants.
Medi-Cal Disclosure Statement DHCS 6207, Revised 11/11 Required for all applicants.
Medi-Cal Hospital-Based Physician Application/Disclosure Statement/Agreement DHCS 9095, New 7/08  
Medi-Cal Change Of Location Form For Individual Physician Or Individual Dentist Practices Relocating Within The Same County DHCS 9096, Revised 01/11  
Medi-Cal Durable Medical Equipment Provider Application DHCS 6201, Revised 1/13  
Medi-Cal Pharmacy Provider Application DHCS 6205, Revised 1/13  
Medi-Cal Specialty Pharmacy Provider Application MC 3155, New 4/10  
Medi-Cal Physician Application/Agreement DHCS 6210, Revised 1/13  
Medi-Cal Provider Application DHCS 6204, Revised 1/13 Required for all provider types for whom a specific application is not listed on this page.
Medi-Cal Clinical Medical Laboratory Application DHCS 6204, Revised 1/13  
Medi-Cal Clinic-Based Certified Nurse Midwife Application DHCS 6204, Revised 1/13  
Medi-Cal Provider Group Application DHCS 6203, Revised 1/13 Application fees are not required for physician and non-physician applicant groups – application form under revision.
Medi-Cal Orthotics and Prosthetics Provider Application DHCS 6202,
Revised 1/13
 
Medi-Cal Nonphysician Medical Practitioner and Licensed Midwife Application DHCS 6248, Revised 1/13  
Medi-Cal Supplemental Changes DHCS 6209, Revised 1/13 Use this form to report changes to previously submitted information. Refer to the complete list of Physician/Non-Physician Medical Practitioner Specialty Codes for assistance completing Box 9 of this form.
Medi-Cal Medical Transportation Provider Application DHCS 6206, Revised 1/13  
Medi-Cal Provider Number Verification Form    
Crossover Only Provider Form MC 0804  
Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers DHCS 6216, Revised 1/13  
Successor Liability with Joint and Several Liability Agreement DHCS 6217, Revised 2/08  
National Provider Identifier Registration Form DHCS 6218, Revised 6/08  


Returned Warrants
The provider number(s) used by a provider are subject to deactivation when warrants or documents mailed to a provider's pay-to address, or its service or business address, are returned by the U.S. Postal Service as not deliverable (W & I Code § 14043.62). Changes in address are to be reported to the Department of Health Care Services (DHCS) within 35 days of the change (22 CCR § 51000.40). Upon notification from DHCS that the address has been updated, the provider may request payments be re-issued by submitting a written request to Xerox State Healthcare, LLC, the DHCS Fiscal Intermediary (FI), at the following address:

Xerox State Healthcare, LLC
c/o Cash Control Unit
P.O. Box 13029
Sacramento, CA 95813-4029

You must include your provider number, warrant number, date issued, and the amount of the warrant on the letter. The FI will re-issue warrants to the pay-to address listed on the Provider Master File (PMF).


Application Tips
Refer to the following tips to assist you in preparing your application package:


Provider Reminders
The following reminders are provided to assist with general provider enrollment issues.

New Provider Enrollment Applications

General Reminders

  • Pay-To Address Changes: Correct Form Use – When reporting a change to your pay-to address, non-institutional providers must use a Medi-Cal Supplemental Changes (DHCS 6209) form to report a change to your pay-to address and/or your mailing address. Institutional providers may use the “Pay-To” Address Change Notification (DHCS 6129) form, which is for institutional provider use only. Only Inpatient, Outpatient and Long Term Care providers are considered Institutional providers. 
  • Business Address Changes – The W & I Code, Section 14043.26(a) states, in relevant part, that “…a provider not currently enrolled at a location where the provider intends to provide services, goods, supplies, or merchandise to a Medi-Cal beneficiary, shall submit a complete application package for enrollment…at a new location or a change in location.”
  • Change of Location for Individual Physicians – Effective July 1, 2008, a Medi-Cal Change of Location Form for Individual Physician Practices Relocating Within the Same County (DHCS 9096) form may be submitted by qualified physicians if all criteria are met. W & I Code, Section 14043.26(b).
  • General Reporting of Changes to Your Medi-Cal Provider Record – It is the provider's responsibility to report to the Department of Health Care Services (DHCS) any modifications to information previously submitted within 35 days of the change. If submitting additional changes to your Medi-Cal record (for example, a new taxpayer identification number, name change or change of ownership), the submission of a new application package is required, pursuant to CCR, Title 22, Sections 51000.30 and 51000.31. When submitting a change to your Medi-Cal record, you can obtain the application package from the Application Forms section of this Web page or by calling the Telephone Service Center (TSC) at 1-800-541-5555.
  • If you are no longer providing Medi-Cal services, you should submit a Medi-Cal Supplemental Changes (DHCS 6209) form to deactivate your provider number. This will minimize the risk of someone fraudulently using your provider number.

Moratoriums
Click the following links for the effective dates, scope and exemptions of current provider enrollment moratoriums:


Top Provider Denial Reasons
Click the following links to review top provider denial reasons:



Note:

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