State of California--Health and Human Services Agency Department of Health Care Services TOBY DOUGLAS Director EDMUND G. BROWN JR. Governor Dear Applicant: Thank you for your recent inquiry regarding participation in the Medi-Cal program. Please complete the enclosed Medi-Cal provider enrollment application package and return it to: Department of Health Care Services Provider Enrollment Division MS 4704, P.O. Box 997412 Sacramento, CA 95899-7412 Please read all the instructions included in the application package carefully and complete each item requested. Incomplete application packages will be returned. PLEASE NOTE: Applicants and providers are required to submit their National Provider Identifier (NPI) with each Medi-Cal provider application package. Applicants are required to attach a copy of the CMS/National Plan and Provider Enumeration System (NPPES) confirmation for each NPI listed in the application package. If providers are not eligible to receive an NPI, they should instead enter the word "atypical" in any NPI fields. These "atypical providers" will receive a unique Medi-Cal provider number once the application is approved. It is your responsibility to report to the DHCS any modifications to information previously submitted within 35 days from the date of the change. Most changes may be reported on a Medi-Cal Supplemental Changes (DHCS 6209, rev. 2/08) form. However, you must complete a new application package if you are reporting a change of ownership of 50 percent or more, a change of business address, or one of the other changes identified in Title 22, California Code of Regulations (CCR), Section 51000.30, subsections (a) through (b). If you are planning to sell your business or buy an existing business, you may find it helpful to refer to the Medi-Cal Provider Enrollment page at www.medi-cal.ca.gov. The Provider Enrollment page contains information about enrollment options available to you whenever there is a sale or purchase of a Medi-Cal enrolled provider or business, including the option to submit a Successor Liability with Joint and Several Liability Agreement. Enrollment forms are available at www.medi-cal.ca.gov or by contacting the Telephone Service Center at 1-800-541-5555. For more information about the forms Provider Enrollment Division, MS 4704, P.O. Box 997412, Sacramento, CA 95899-7412 (916) 323-1945 Internet Address: www.dhcs.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com and the regulatory requirements for participation in the Medi-Cal program, please visit our Web site at www.medi-cal.ca.gov and click the "Provider Enrollment" link. If you have any additional enrollment questions, please contact the Provider Enrollment Message Center at (916) 323-1945, or submit your question(s) to the address above or via email at PEDCorr@dhcs.ca.gov. In order to submit claims electronically, providers must request a submitter number by completing the Medi-Cal Telecommunications Provider and Biller Application/Agreement (DHCS 6153, rev. 12/07), available on the Medi-Cal Web site at www.medi-cal.ca.gov by clicking the "Forms" link in the "Featured" area, then "Billing." Provider Enrollment Division Enclosures (Revised 1/11) American LegalNet, Inc. www.FormsWorkFlow.com State of California-Health and Human Services Agency Department of Health Care Services INSTRUCTIONS FOR COMPLETION OF THE MEDI-CAL NONPHYSICIAN MEDICAL PRACTITIONER AND LICENSED MIDWIFE APPLICATION DO NOT USE staples on this form or on any attachments. DO NOT USE correction tape, white out, or highlighter pen or ink of similar type on this form. If you must make corrections, please line through, date and initial in ink. DO NOT LEAVE any questions, boxes, lines, etc. blank. Enter N/A if not applicable to you. This form is part of an application for enrollment or continued enrollment as a provider in the Medi-Cal program. Applicants and providers must also provide additional information and documentation. Applicants and providers may be subject to an on-site inspection and to unannounced visits prior to enrollment or approval for continued enrollment in a program. In addition to this form and requested documentation, a MEDI-CAL DISCLOSURE STATEMENT (DHCS 6207) and a MEDI-CAL PROVIDER AGREEMENT (DHCS 6208) must also be completed for enrollment or continued enrollment. Additional information can be found on the Medi-Cal Web site (www.medi-cal.ca.gov) by clicking the "Provider Enrollment" link. Omission of any information or documentation on this form or failure to sign any of these documents may result in any of the denial actions identified in California Code of Regulations (CCR), Title 22, Section 51000.50. You must attach copies of Centers for Medicare and Medicaid Services/National Plan and Provider Enumeration System (CMS/NPPES) confirmation for each National Provider Identifier (NPI) submitted with your application package. You may not submit an NPI for use in Medi-Cal billing unless that NPI is appropriately registered with CMS and is in compliance with all NPI requirements established by CMS at the time of submission. Enrollment action requested (check all that apply). Enter the date you are completing the application. "Add new"--the Nonphysician Medical Practitioner or Licensed Midwife is not currently enrolled in the Medi-Cal program under the listed Employing Provider. "Delete"--you no longer wish to be enrolled as a practitioner under the listed Employing Provider. "Change"--you need to change information previously submitted to the Department. "Continued Enrollment"--you are currently enrolled in the Medi-Cal program and would like to continue participation. (Do not check this box unless you have been requested by the Department to apply for continued enrollment in the Medi-Cal program pursuant to CCR, Title 22, Section 51000.55) Note: If you are enrolling as an individual provider do not submit this application form. Please submit a MEDI-CAL PROVIDER APPLICATION (DHCS 6204), a MEDI-CAL DISCLOSURE STATEMENT (DHCS 6207) and a MEDI-CAL PROVIDER AGREEMENT (DHCS 6208). A. Nonphysician Medical Practitioner or Licensed Midwife Information 1. "Legal name"--enter the name listed with the Internal Revenue Service (IRS). 2. Enter driver's license number or state-issued identification card number and state of issuance. Attach a legible copy. 3. Enter the Nonphysician Medical Practitioner or Licensed Midwife's National Provider Identifier. Attach a copy of the CMS/NPPES confirmation. 4. Enter