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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
- Application Forms by Form Name and Number
- Application Packages Alphabetical by Provider Type
- Clinic-Based Certified Nurse Midwife Enrollment
- Clinic-Based Physician Enrollment
- Crossover Only Provider Authorization Information
- Current Information on Preferred Provider Status
- Facility-Based Providers Enrollment
- Hospital-Based Physician Enrollment
- NMP Enrollment Requirements for Medi-Cal
- Ordering/Referring/Prescribing Only Enrollment Instructions and Requirements
- Returned Warrants
- Application Tips
- Provider Reminders
- Frequently Asked Questions
- Top Provider Denial Reasons
- Contact Provider Enrollment
- Suspended and Ineligible Provider List
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:
- Federal Deficit Reduction Act 2005: Employee Education on False Claims Recovery Published in the December 2006 Medi-Cal Update.
- 2012-2013 Certificate of Compliance Employee education on false claims recovery.
- California Welfare and Institutions Code (W & I Code), Section 14043 Includes Senate Bill 857 changes.
- Provider Enrollment Regulations (California Code of Regulations, Title 22) Effective July 1, 2008.
- Provider Enrollment Regulations (California Code of Regulations, Title 22) Effective January 1, 2008.
- Provider Enrollment Regulations (California Code of Regulations, Title 22) Effective November 10, 2005.
- Provider Enrollment Regulations (California Code of Regulations, Title 22) Effective October 7, 2004.
- Senate Bill 857 Amends the California Welfare and Institutions Code (W & I Code), Section 14043; effective January 2004.
- Senate Bill 857: Impact to Medi-Cal Providers Published in the December 2003 Medi-Cal Update.
- Reminder – Suspension of Entities Submitting Claims for Suspended Providers Published in the December 2006 Medi-Cal Update. References the Medi-Cal Suspended and Ineligible Provider List (S&I List) and the Health and Human Services (HHS) Office of Inspector General List of Excluded Individuals/Entities.
- Provider Bulletins – Provider enrollment policies and procedures issued based on the authority granted to the director of DHCS in the W & I Code, Section 14043.75(b) that have the full force and effect of law.
- Updated Applications Required for Durable Medical Equipment Providers – Effective May 1, 2014, the Department of Health Care Services (DHCS) is revising the Medi-Cal Pharmacy Provider Application (DHCS 6205) and the Medi-Cal Durable Medical Equipment Provider Application (DHCS 6201) to include detailed lists of business activities.
- Continued Certification for Drug Medi-Cal Providers – Informational bulletin on the continued statewide certification process for all certified Drug Medi-Cal providers.
- Medi-Cal Requirement to Report Provider Enrollment Terminations – In accordance with Section 1902(kk)(6) of the Social Security Act and in accordance with 42 Code of Federal Regulations (CFR) Section 455.416(c) published on February 2, 2011, in the Federal Register to implement the Patient Protection and Affordable Care Act (ACA) of 2010, the director of California's Department of Health Care Services (DHCS) is issuing this informational provider bulletin.
- Provisions of the Affordable Care Act Create New Medi-Cal Provider Application Screening and Enrollment Requirements – On January 1, 2013, California Senate Bill 1529, which implements sections of the Affordable Care Act of 2010 that pertain to Medicaid provider screening and fraud prevention, becomes effective as state law.
- Medi-Cal Screening Level Requirements for Compliance with 42 Code of Federal Regulations Section 455.450 – In accordance with the Centers for Medicare and Medicaid Services (CMS), the Department of Health Care Services (DHCS) is implementing Medi-Cal screening level requirements to comply with 42 Code of Federal Regulations (CFR) Section 455.450 and California Welfare & Institutions Code (W&I Code), Section 14043.38.
- Medi-Cal Requirement for Ordering/Referring/Prescribing Providers Forms and Procedures – In accordance with the Centers for Medicare and Medicaid Services (CMS), the Department of Health Care Services (DHCS) is establishing the requirement for the Medi-Cal program to enroll ordering, referring or prescribing only providers in accordance with 42 Code of Federal Regulations (CFR) Section 455.410 and 42 CFR Section 455.440.
- Medi-Cal Application Fee Requirements for Compliance with 42 Code of Federal Regulations Section 455.460 – In accordance with the Centers for Medicare and Medicaid Services (CMS), the Department of Health Care Services (DHCS) is establishing the Medi-Cal application fee requirements to implement 42 Code of Federal Regulations (CFR) Section 455.460.
- Revised Medi-Cal Provider Disclosure Requirements for Compliance with 42 Code of Federal Regulations – Effective November 15, 2011, in accordance with Centers for Medicare and Medicaid Services (CMS) requirements, the Department of Health Care Services (DHCS) is revising provider disclosure statements and provider agreements.
- Crossover Only Providers Approval for Reimbursement Effective immediately, a new form is available for use by Crossover Only Providers who are seeking reimbursement for services rendered to dual-eligible beneficiaries. This form is to be used solely for approval for reimbursement by Crossover Only Providers and not for general Medi-Cal enrollment.
- Requirements and Procedures for ‘Clinic-Based Certified Nurse Midwife’ Enrollment This bulletin provides a supplement to the current enrollment requirements of the Medi-Cal program for certified nurse midwives.
- AB 1226 – Physician Forms & Provisions Effective July 1, 2008 Effective for dates of service on or after July 1, 2008, Welfare and Institutions (W & I Code), Section 14043.26(b) and (e) allow doctors of medicine and osteopathic physicians who meet specified criteria, and who change their business locations within the same county, to use a “change of location” form.
- NPI Registration for Facilities Facilities licensed and/or certified by the California Department of Public Health (CDPH) that find that National Provider Identifier Collection (NPIC) does not allow them to accurately register their National Provider Identifiers (NPIs) may do so by submitting a letter to the Department of Health Care Services’ Provider Enrollment Division (PED).
- Provider Enrollment Application Changes Due to NPI Effective February 15, 2008, in accordance with Centers for Medicare & Medicaid Services (CMS) requirements, the Department of Health Care Services (DHCS) is revising all provider enrollment application forms to accommodate the National Provider Identifier (NPI).
- Assembly Bill 1226 – Provisions Affect All Providers – Effective for dates of service on or after January 1, 2008, Assembly Bill (AB) 1226 has two provisions, that affect all providers, and that amend the laws the Department of Health Care Services (DHCS) uses to review provider applications for participation in the Medi-Cal program.
- Important Reminder: Providers Selling or Purchasing a Business – As introduced in regulation package R-04-04E, the Department of Health Care Services (DHCS) wishes to remind providers of the ability to accept successor liability with joint and several liability requirements.
- Revised Application Form Requirements, Procedures Due to NPI Implementation – Effective May 23, 2007, applicants and providers will be required to submit their National Provider Identifier (NPI) with each Medi-Cal provider application package.
- New Versions of Provider Applications and Disclosure Forms – All required provider application and disclosure forms have been revised to comply with the disclosure requirements of California Code of Regulations (CCR), Title 22, Sections 51000.30, 51000.31, 51000.32, 51000.35 and 51000.40. Published in the March 2006 Medi-Cal Update.
- Changes to Rendering Provider Enrollment Process – Effective immediately, rendering providers within provider groups no longer need to re-enroll for every group and location where they practice. Published in the December 2005 Medi-Cal Update.
- Requirements and Procedures for 'Clinic-Based Provider' Enrollment – Intended to provide a supplement to the enrollment requirements currently applicable to physicians who are solely employed by or provide services pursuant to a contract with licensed primary care clinics, except for services provided as part of a graduate medical education program, and who do not have any active Medi-Cal provider numbers issued to them individually to bill for clinical services to Medi-Cal beneficiaries at another location. Published in the December 2005 Medi-Cal Update.
- Requirements and Procedures for Successor Liability – Pursuant to the California Code of Regulations (CCR), Title 22, Sections 51000.20.1, 51000.24.1, 51000.25.2, 51000.32 as introduced in regulation package R-04-04E, the Department of Health Care Services (DHCS) is introducing the ability for providers to accept successor liability with joint and several liability requirements. Published in the December 2005 Medi-Cal Update.
- Requirements and Procedures for Enrollment as a 'Facility-Based Provider' – Published in the February 2005 Medi-Cal Update.
- Effective Date of Enrollment How DHCS determines “the date on the notice” when granting provisional or preferred provisional provider status under the W & I Code, Section 14043.26 and an exception for contractors for hospital-based services for emergency care. Published in the June 2004 Medi-Cal Update.
- Preferred Provider Status How physicians can request, and provide documentation and verification for, consideration for enrollment in the Medi-Cal program as a Preferred Provisional Provider. Published in the February 2004 Medi-Cal Update.
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 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,
|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|
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).
Refer to the following tips to assist you in preparing your application package:
The following reminders are provided to assist with general provider enrollment issues.
New Provider Enrollment Applications
- Two New Physician Enrollment Forms - Effective July 1, 2008, physicians who meet specified criteria and change their business location within the same county may use the Medi-Cal Change of Location Form for Individual Physician Practices Relocating Within the Same County (DHCS 9096) form. Physicians who meet specified criteria and have a medical practice based exclusively in hospitals as defined in California Health and Safety Code Section 1250, subsections (a) and (b), may enroll using the Medi-Cal Hospital-Based Physician Application/Disclosure Statement/Agreement (DHCS 9095) form. See the provider bulletin article: AB 1226 – Physician Forms & Provisions Effective July 1, 2008 for more information.
- Providers, please take note, one of the most common reasons for an application being denied is that the application is not a current version or not a correct application for the provider type.
- 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.
Click the following links for the effective dates, scope and exemptions of current provider enrollment moratoriums:
- Clinical Laboratories
- Durable Medical Equipment Providers
- Los Angeles County Non-Chain, Non-Pharmacist Owned Pharmacy moratorium
Top Provider Denial Reasons
Click the following links to review top provider denial reasons:
If you cannot view the MS Word or PDF (Portable Document Format) documents correctly, please visit the Web Tool Box to link to a download site for the appropriate reader.