Medi-Cal Pharmacy Provider Application Form. This is a California form and can be use in Medi Cal Statewide.
Tags: Medi-Cal Pharmacy Provider Application, DSH-6205, California Statewide, Medi Cal
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BROWN JR. OVERNO R r addresse s n tifier (NPI) f the Cent e N PPES) c eive an N P l receive a r ogram as d e of a ge under o or D epartment t ion fee wh e o nducting t h Please t s for ired g eles Cou n o llowing th e d checks fr o 4 24.518, n r ollment du e r ical risk le v s rs P I, of e n h e n ty e o m e v el. American LegalNet, Inc. www.FormsWorkFlow.com A 223high224 risk screening requires a provider or applicant to submit proof that fingerprints for all the required individuals have been submitted to an authorized State Identification Bureau (Department of Justice [DOJ], Bureau of Criminal Information and Analysis, in California). Providers and applicants must attach a copy of a prefilled DOJ Request for Live Scan Service (BCIA 8016) form for each required individual with their application date-stamped and show verification that all fees have been paid by either a 223PAID224 stamp from the public Live Scan operator or a receipt of payment. If you would have met one of the exemptions listed below, you do not need to be screened as 223high224 risk but you must submit a cover letter with your application advising which exemption you meet and include any necessary supporting documentation: 1. The enrollment of chain pharmacy providers. For the purposes of this moratorium, a chain pharmacy is defined as an entity with 20 or more service locations. 2. The enrollment of a county, state or federally owned and operated pharmacy 3. Applicants who will be enrolled solely for reimbursement of Medicare cost sharing amounts 4. Applications submitted by a provider to operate at the same business location as a Federally Qualified Health Center (FQHC). The pharmacy, in whole or in part, must be owned and operated by the same entity that owns the FQHC. 5. Applications submitted by an academic specialty pharmacy. For purposes of this moratorium, an academic specialty pharmacy is defined as a specialty pharmacy that is owned or operated by a higher education institution that is currently a Medi-Cal pharmacy provider. If the department determines that you do not meet an exemption or if you do not want to go through an exemption review, you are required to be screened at the 223high224 categorical risk level and submit fingerprints for a criminal background check. Failure to submit fingerprints for a criminal background check when required will result in the denial of the application package (CFR, Title 42, Section 455.416; W&I Code, Section 14043.26[f][E]). Additional information about the Medi-Cal requirements for submitting fingerprints is available in the 223Medi-Cal Requirement to Submit Fingerprints for a Criminal Background Check224 provider bulletin. Return the completed application package 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. American LegalNet, Inc. www.FormsWorkFlow.com It is your responsibility to report to DHCS any modifications to information previously submitted within 35 days from the date of the change. Most changes can be reported on a Medi-Cal Supplemental Changes form (DHCS 6209, Rev. 2/18). However, you must complete a new application package if you are reporting a change of business ownership of 50 percent or more, a change of business address, or one of the other changes identified in CCR, Title 22, Section 51000.30, subsections (a) through (b). If you are planning to sell your business or buy an existing business, the Provider Enrollment page of the Medi-Cal website contains information about enrollment options available to you whenever there is a sale or purchase of a Medi-Cal enrolled pharmacy, including the option to submit a Successor Liability with Joint and Several Liability Agreement (DHCS 6217, Rev. 5/17). Enrollment forms are available on the Provider Enrollment page of the Medi-Cal website or by contacting the Medi-Cal Telephone Service Center (TSC) at 1-800-541-5555. For more information about the forms, form completion and the regulatory requirements for participation in the Medi-Cal program, please visit the Provider Enrollment page of the Medi-Cal website. For additional enrollment questions, you may contact the PED Message Center at (916) 323-1945, ext. 4522, or submit your question(s) to the address above or via email to PEDCorr@dhcs.ca.gov. Providers or provider representatives who intend to use the Medi-Cal Point of Service (POS) network or Medi-Cal website applications must compl