Welcome to the Department of Health Care Services (DHCS), Provider Enrollment Division (PED) Web page. Thank you for your interest in becoming a provider in the Medi-Cal program. Our mission is to:

"Enroll eligible providers in the Medi-Cal program on a timely basis and continually update the Provider Master File to accurately reflect provider status."

PED is responsible for the enrollment and re-enrollment of fee-for-service health care service providers into the Medi-Cal program. There are approximately 130,000 Medi-Cal providers who serve the medically necessary needs of Medi-Cal recipients. 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
• Returned Warrants
• Application Tips
• Enrolling as a New Medi-Cal Provider (Application Forms Required Reference Chart)
• Provider Reminders
• Moratoriums
• Frequently Asked Questions
• Contact Provider Enrollment

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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.
• 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 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.
  • 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.

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Application Forms
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.

• Medi-Cal Provider Agreement (DHCS 6208, revised 2/08) – 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 8/08) – Required for all institutional applicants.
• Medi-Cal Disclosure Statement (DHCS 6207, revised 2/08) – 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 Practices Relocating Within the Same County (DHCS 9096, new 7/08)
• Medi-Cal Durable Medical Equipment Provider Application (DHCS 6201, revised 2/08)
• Medi-Cal Pharmacy Provider Application (DHCS 6205, revised 5/08)
• Medi-Cal Physician Application/Agreement (DHCS 6210, revised 2/08)
• Medi-Cal Provider Application (DHCS 6204, revised 2/08) – 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 2/08)
• Medi-Cal Provider Group Application (DHCS 6203, revised 2/08)
• Medi-Cal Orthotics and Prosthetics Provider Application (DHCS 6202, revised 2/08)
• Medi-Cal Nonphysician Medical Practitioner and Licensed Midwife Application (DHCS 6248, revised 2/08)
• Medi-Cal Supplemental Changes (DHCS 6209, revised 2/08) – 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 2/08)
• Medi-Cal Provider Number Verification Form
• Medi-Cal Provider Data Form (MC 803)
• Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers (DHCS 6216, revised 2/08)
• Successor Liability with Joint and Several Liability Agreement (DHCS 6217, revised 2/08)
• National Provider Identifier Registration Form (DHCS 6218, revised 6/08)

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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 EDS at the following address:

EDS 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. EDS will re-issue warrants to the pay-to address listed on the Provider Master File (PMF).

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

• How to Complete a Physician Application Package
• How to Submit a Complete Application Package

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Enrolling as a New Medi-Cal Provider (Application Forms Required Reference Chart)
The following chart is provided to assist you in choosing your application and required attachments when applying to the Medi-Cal program for the first time:

• New to Medi-Cal Provider Application Reference Chart

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Provider Reminders
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.

General Reminders

• Pay-To Address Changes: Correct Form Use – When reporting a change to your pay-to address, please note that the “Pay-To” Address Change Notification (DHCS 6129) form is for institutional provider use only. Only Inpatient, Outpatient and Long Term Care providers are considered Institutional providers. If you are not an institutional provider, you must use a Medi-Cal Supplemental Changes (DHCS 6209) form to report a change to your pay-to address and/or your mailing address.
• 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.

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

• Adult Day Health Care (ADHC) Centers
• Clinical Laboratories
• Durable Medical Equipment Providers
• Non-Chain Non-Pharmacist Owned Los Angeles County Pharmacy Providers

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Frequently Asked Questions
Click the following link to review answers to frequently asked provider enrollment questions:

• Medi-Cal Provider Enrollment Frequently Asked Questions
• Top Reasons Provider Enrollment Applications are Denied
• Top Reasons Preferred Provider Enrollment Applications are Denied

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Contact Provider Enrollment
Applicants are encouraged to carefully read the instructions provided with the application forms. For more information about the forms and the regulatory requirements for participation in the Medi-Cal program, please review the information provided in other sections above.  Staff is not available to provide a status update on the processing of applications and does not provide advisory opinions.  However, if you have any additional questions concerning enrollment policy or forms, please call the Provider Enrollment Message Center at (916) 323-1945, or submit your questions via e-mail to PEDCorr@dhcs.ca.gov, or in writing to:

Department of Health Care Services
Provider Enrollment Division
MS 4704
P.O. Box 997413
Sacramento, CA 95899-7413