State of California—Health and Human Services Agency Department of Health Care Services EDMUND G. BROWN JR. Governor TOBY DOUGLAS Director 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 PROVIDER GROUP 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 a similar type on this form. If you must make corrections, please line through, date, and initial in ink. DO NOT LEAVE any question, 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 Title 22, California Code of Regulations (CCR), 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. “New provider” - check if the applicant is not currently enrolled in the Medi-Cal program as a provider with an active provider number. Include the NPI (or Denti-Cal provider number if applicable) for the business address indicated in item 4. “Change of business address”—check if the applicant is currently enrolled in the Medi-Cal program and is requesting to relocate to a new business address and vacate the old location. Indicate the business address applicant is moving from. “Additional business address”—check if the applicant is currently enrolled in the Medi-Cal program and is requesting enrollment for an additional business location. “New Taxpayer ID Number”—check if a new Taxpayer Identification Number (TIN) has been issued by the IRS. “Change of ownership”—check if there is a change of ownership as defined in Title 22, CCR, Section 51000.6. Indicate the effective date in the space provided. “Cumulative change of 50 percent or more in person(s) with ownership or control interest”—check if there is a cumulative change of 50 percent or more in the person(s) with ownership or control interest, as defined in Title 22, CCR, Section 51000.15, since the information provided in the last complete application package that was approved for enrollment. Indicate the effective date in the space provided. “Sale or transfer of assets (50 percent or more)”—check if 50 percent or more of the assets owned by the corporation, at the location for which a provider number has been issued, are sold or transferred. Indicate the effective date in the space provided. “Continued Enrollment”—check if the applicant is currently enrolled as a Medi-Cal provider and has been requested by the Department to apply for continued enrollment in the Medi-Cal program. Do not check this box unless you have received notification from the Department, pursuant to Title 22, CCR, Section 51000.55. List current provider number(s) in the space provided. Check the box labeled “I intend to use my current . . . .” if you intend to use your current provider number to bill for services delivered at this location while this application request is pending. This action places the provider on provisional provider status, pursuant to Title 22, CCR, Section 51000.51. “Type of entity”—check the box which applies to your business structure. Your corporate status will be verified using the corporate number and state in which incorporated. If a partnership, you must attach a legible copy of the partnership agreement. If you check “other,” list the type of legal entity. 1. “Legal name” is the name listed with the Internal Revenue Service (IRS). 2. “Business name” is the name of the applicant or provider if different from that listed in number 1. If this is a Fictitious Business Name, provide the Fictitious Business Name Statement/Permit number and effective date. Attach a legible copy of the recorded/stamped Fictitious Business Name Statement/Permit to the application. Physician provider groups are to submit a legible copy of the Fictitious Business Name Permit issued by the Medical Board of California. DHCS 6203 (rev. 2/08) Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com 3. “Provider group telephone number” is the primary business telephone number used at the business address. A beeper number, cell phone, answering service, pager, facsimile machine, biller or billing service phone, or answering machine shall not be used as the primary business telephone. 4. “Business address” is the actual business location including the street name and number, room or suite number or letter, city, county, state, and nine-digit ZIP code. A post office or commercial box is not acceptable. a. Check whether the business address is a licensed health facility as defined in Sections 1250,1250.2 and 1250.3 of the Health and Safety Code. Check whether services will be rendered at only the business address indicated. If not, you must submit a separate application for each business address unless you qualify for an exception pursuant to Welfare and Institutions Code Section 14043.15(b)(2). See the ‘Facility-Based Provider’ bulletin at the Medi-Cal program Website (www.medi-cal.ca.gov) for the requirements to qualify for that exception. 5. “ Pay-to address” is the address to which payment will be mailed. The pay-to address should include, as applicable, the post office box number, street number and name, room or suite number or letter, city, state, and nine-digit ZIP code. 6. “Mailing address” is the address at which the applicant or provider wishes to receive general Medi-Cal correspondence. General Medi-Cal correspondence includes bulletin updates and Provider Manual updates. 7. “Previous business address” is the address where the applicant or provider was previously enrolled. If the applicant or provider is not submitting an application for a change of location, enter N/A. 8. Enter the Taxpayer Identification Number (TIN) issued by the IRS under the name of the provider group or provider group applicant; or enter social security number (see Privacy Statement on page 6). Attach a legible copy of the IRS Form 941, Form 8109-C, Letter 147-C, or Form SS-4 (Confirmation Notification). 9. Enter any additional NPI for the business address indicated in item 4, registered with other carriers including, but not limited to Medicare. Attach CMS/NPPES verification for each. Providers not eligible to receive an NPI (atypical providers) should submit a Medicare billing number. 10. Enter the Seller’s Permit number issued by the State Board of Equalization. Attach a legible copy of the Seller’s Permit. 11. Enter each taxonomy code(s) associated with your NPI. Attach additonal sheets if necessary. 12. Indicate the type of provider group (e.g. Audiologists, Certified Nurse Midwives, Chiropractors, Occupational Therapists, Optometrists, Orthotists, Orthotists and Prosthetists, Nurse Anesthetists, Nurse Practitioners, Physicians, Physical Therapists, Podiatrists, Prosthetists, Psychologists, Respiratory Therapists, Speech Therapists, Dentists, Registered Dental Hygienist Alternative Practice). 13. If this is a physician provider group, or dentist provider group, list the specialty(ies). 14. List the name, professional license number, social security number, and date of birth of all rendering providers in the provider group. Attach additional sheets, if necessary. Except as noted below, rendering providers not already currently enrolled as Medi-Cal providers who are enrolling to render services in the provider group must use the “Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers” (DHCS 6216). Provision of the social security number is optional (see Privacy Statement on page 6). The following providers, enrolling to render services in a Medi-Cal enrolled provider group, must use the “ Medi-Cal Nonphysician Medical Practitioner and Licensed Midwife Application” (DHCS 6248), the “Medi-Cal Provider Agreement” (DHCS 6208) and the “Medi-Cal Disclosure Statement” (DHCS 6207) to enroll: Licensed Midwives Nurse Anesthetists Nurse Midwives Nurse Practitioners Physician Assistants 15a. If this is a physician provider group, enter information on whether the physicians have hospital privileges. If not please explain why (if arrangements have been made with another physician for admitting patients, please provide his/her name, address, and telephone number). Provide the name(s) of the physician(s) and the name(s), address(es) and telephone number(s) of the hospital(s) where current privileges have been granted. Attach an additional sheet supplying all of the requested information for each hospital if needed. 15b. If this is a physician provider group, enter information on whether any of the physicians have had privileges at any hospitals that were suspended or revoked. If so, provide the name(s) of the physician(s) and the name(s), address(es), and telephone number(s) of the hospital(s). Attach an additional sheet supplying all of the requested information for each hospital if needed. 15c. If this is a physician provider group, enter information on whether the applicant or provider has voluntarily resigned or otherwise surrendered their hospital privileges. If so, provide the name(s) of the physician(s) and the name(s), address(es), and telephone number(s) of the hospital(s). Attach an additional sheet supplying all of the requested information for each hospital if needed. DHCS 6203 (rev. 2/08) Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com 16. Enter the Clinical Laboratory Improvement Amendment (CLIA) Certificate number. Attach a legible copy of the CLIA Certificate. 17. Enter the State Laboratory License/Registration number. If this does not apply to you, enter “N/A.” Attach a legible copy of the license/registration. 18. Enter any local business license or permit numbers for any city and/or county where you conduct your business and attach copies to the application. If this does not apply to you, enter N/A and provide an explanation. 19. Enter the requested information. Attach to this application a legible copy(ies) of applicant’s current Certificate of Insurance for Liability Insurance that covers premises and operation for this address. If all services are provided exclusively in a licensed hospital or licensed health facility (as defined in Health and Safety Code, Section 1250), please provide a cover letter with the facility information as proof of liability insurance coverage in accordance with the February 2005 Provider Bulletin regarding Facility Based Providers. 20. Enter the requested information. Attach a legible copy(ies) of applicant’s current Certificate of Insurance for Professional Liability Insurance (malpractice insurance) to this application. 21. Check the appropriate box to indicate whether you have worker’s compensation insurance as required by state law. If applicable, attach proof. If not applicable, check N/A and provide an explanation. 22. “Printed name of provider”—print the last, first, and middle name of the provider as the sole proprietor, partner, corporate officer, or government official when applying to the Department of Health Care Services for enrollment or continued enrollment as a provider in the Medi-Cal program. 23. Check the gender of the individual named in number 22. 24. Enter the driver’s license or state-issued identification card number and state of issuance of the individual named in number 22. Attach a legible copy to the application. The driver’s license or state-issued identification number shall be issued within the 50 United States or the District of Columbia. 25. Enter the date of birth of the individual named in number 22. 26. Enter the social security number of the individual named in number 22. Provision of the social security number is optional (see Privacy Statement on page 6). 27. An original signature of the individual named in number 22 is required. Also provide the title of the person signing the application. Include the city, state, and the date where and when the application was signed. See Title 22, CCR Section 51000.30(a)(2)(B) to determine whether you have the authority to sign this application. 28. Applicants and providers licensed pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, the Osteopathic Initiative Act, or the Chiropractic Initiative Act ARE NOT REQUIRED to have this form notarized. If it must be notarized, the Certificate of Acknowledgement signed by the Notary Public must be in the form specified in Section 1189 of the Civil Code. 29. Enter contact information for the provider or other authorized person designated for Provider Enrollment staff to contact for clarification. Failure to include this information may result in the application package being returned deficient for item(s) that an applicant can readily provide by fax or telephone. Remember to attach a legible copy of the following, if applicable: TIN verification Seller’s Permit Fictitious Business Name Statement or Fictitious Name Permit Signed Medi-Cal Disclosure Statement (DHCS 6207) Signed Medi-Cal Provider Agreement (DHCS 6208) Complete “Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement For Physician/Allied Providers” (DHCS 6216) for each rendering provider being added to the provider group if the rendering provider is not currently enrolled as a Medi-Cal Provider” Applicable certifications Driver’s license or state-issued identification card of individual signing the application CLIA Certificate State Laboratory License/Registration Certificate of Liability Insurance Certificate of Professional Liability Insurance Proof of Worker’s Compensation Insurance Medicare enrollment verification Successor Liability Agreement National Provider Identifier (NPI) verification (CMS/NPPES verification) DHCS 6203 (rev. 2/08) Page 3 of 6 American LegalNet, Inc. www.FormsWorkFlow.com State of California—Health and Human Services Agency Department of Health Care Services MEDI-CAL PROVIDER GROUP APPLICATION FOR STATE USE ONLY Important: Read all instructions before completing the application. Type or print clearly, in ink. If you must make corrections, please line through, date, and initial in ink. For Medi-Cal return completed forms to: For Denti-Cal return completed forms to: Department of Health Care Services Medi-Cal Dental Program (Denti-Cal) Provider Enrollment Division Provider Enrollment MS 4704 P.O. Box 15609 P.O. Box 997413 Sacramento, CA 95852-0609 Sacramento, CA 95899-7413 (800) 423-0507 (916) 323-1945 Do not use staples on this form or on any attachments. Do not leave any questions, boxes, lines, etc. blank. Enter N/A if not applicable to you. Date Provider number (NPI or Denti-Cal provider number as applicable): ___________________ / Enrollment action requested (check all that apply) New provider Change of business address Additional business address New Taxpayer ID number Facility-Based Provider *Change of ownership (per Title 22, CCR, Section 51000.6) *Acceptance of “Successor Liability with Joint and Several Liability” (per Title 22, CCR, Sections 51000.24.1, 51000.32) *Cumulative change of 50 percent or more in person(s) with ownership or control interest (per Title 22, CCR, Section 51000.15) *Sale or transfer of assets (50 percent or more) (per Title 22, CCR, Section 51000.30) / Continued enrollment (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 Title 22, CCR, Section 51000.55.) * I intend to use my current provider number to bill for services delivered at this location while this application request is pending. I understand that I will be on provisional provider status during this time, pursuant to Title 22, CCR, Section 51000.51. A provider agreement may not be transferred or assigned to another. However, an applicant may be joined to the provider agreement by strict compliance with the provisions of Title 22, CCR, Section 51000.32 entitled “Requirements for Successor Liability with Joint & Several Liability.” Indicate the change of ownership effective date: _____/_____/_____. For items above marked with * indicate effective date: ____/___/____. Type of entity (check one) Sole proprietor Partnership Government entity Corporation: Corporate number: ______________ State incorporated: ______________ Limited Liability Company (LLC): LLC number: ___________________ State registered/filed: ____________ Nonprofit Corporation Type of nonprofit: ____________________ Other: _____________________________ 1. Legal provider group name (as listed with the IRS) 2. Business name, if different Is this a fictitious business name? Yes If yes, list the Fictitious Business Name Statement/Permit number Effective date / No 3. Provider group telephone number ( / ) (Attach a legible copy of the recorded/stamped Fictitious Business Name Statement/Permit.) 4. Provider group business address (number, street) City a. If you are applying as a facility-based provider, complete this section: This address is a licensed hospital/health facility. Yes No County State Nine-digit ZIP code If yes, check the option that applies: All services are provided at this one facility location OR Services are provided at more than one licensed health facility (Attach a list of all business addresses where services are provided). 5. Pay-to address (number, street, P.O. Box number) City State Nine-digit ZIP code 6. Mailing address (number, street, P.O. Box number) City State Nine-digit ZIP code For a change of business address, enter location moving from: 7. Previous business address (number, street) City State Nine-digit ZIP code 8. Taxpayer Identification Number (TIN) or social security number (Attach a legible copy of the IRS form) 9. Medicare/Other NPI (see instructions) 11. Primary Taxonomy Code Taxonomy Code 12. Type of provider group 10. Seller’s Permit number (attach a legible copy) 13. If physician(s) or dentist(s), list specialty(ies) DHCS 6203 (rev. 2/08) Taxonomy Code Page 4 of 6 American LegalNet, Inc. www.FormsWorkFlow.com 14. List all providers rendering in the provider group. (Use additional sheets if necessary. Attach complete application package for each provider not enrolled in the Medi-Cal program.) Name Provider Number License Number Social Security Number Date of Birth / / / / / / / / 15. Hospital Privileges (answer if a physician provider group) a. Do all of your physicians have current hospital privileges? Yes No If no, please explain:___________________________________________________________________________________________________________________________ If yes, please enter the following (attach additional sheets if needed): Name of physician Name of Hospital Telephone number ( Address (number, street) ) City Name of physician State Name of Hospital Telephone number ( Address (number, street) b. Nine-digit ZIP code ) City State Nine-digit ZIP code Have any of your physician’s hospital privileges ever been suspended or revoked? Yes No If yes, please enter the following (attach additional sheets if needed): Name of physician Name of Hospital Telephone number ( Address (number, street) c. ) City State Nine-digit ZIP code Have any of your physicians ever voluntarily resigned or otherwise surrendered his/her hospital privileges? Yes No If yes, please enter the following (attach additional sheets if needed): Name of physician Name of Hospital Telephone number ( Address (number, street) 16. ) City Clinical Laboratory Improvement Amendment (CLIA) Certificate number (attach a legible copy) State 17. State Laboratory License/Registration number (attach a legible copy) Nine-digit ZIP code 18. Any local business license/permit numbers (attach a legible copy) 19. Proof of Liability Insurance—Applicant must attach a copy of their certificate of insurance for the business address. Name of insurance company Insurance policy number Date policy issued (mm/dd/yyyy) / Insurance agent’s name—(first) / / (middle) / (last) Telephone number Fax number ( ( ) Expiration date of policy (mm/dd/yyyy) (Jr., Sr., etc.) E-mail address ) 20. Proof of Professional Liability Insurance—Applicant must attach a copy of their certificate of (malpractice) insurance to this application. Name of insurance company Insurance policy number Date policy issued (mm/dd/yyyy) / Insurance agent’s name—(first) / / (middle) (last) Telephone number Fax number ( ( ) Expiration date of policy (mm/dd/yyyy) / (Jr., Sr., etc.) E-mail address ) 21. Does the applicant have Worker’s Compensation insurance as required by state law? Yes No N/A If applicable, attach proof of maintenance of Worker’s Compensation insurance. If not applicable, check N/A and provide an explanation: DHCS 6203 (rev. 2/08) Page 5 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Information About Individual Signing This Application 22. Printed name of provider 24. Driver’s license or state-issued ID number and state of issuance (attach a legible copy) (last) (first) 23. Gender (middle) Male 25. Date of birth / / Female 26. Social security number (Optional—see Privacy Statement below.) ____ ____ ____ — ____ ____ — ____ ____ ____ ____ 27. I declare under penalty of perjury under the laws of the State of California that the foregoing information in this document, in the attachments, the disclosure statement, and provider agreement are true, accurate, and complete to the best of my knowledge and belief. I declare that I have the authority to legally bind the applicant or provider pursuant to Title 22, CCR Section 51000.30(a)(2)(B). Signature of provider Title Executed at: _______________________________________, _____________________________________ (City) / / on _________________________ (State) (Date) 28. Notary Public — Please see instructions under number 28 for who must have their application signed by a Notary Public in the form specified by Section 1189 of the Civil Code. 29. Contact Person’s Information Check here if you are the same person identified in item 22. If you checked the box, provide only the e-mail address and telephone number below. (first) (middle) (gender) Contact Person’s Name (last) Male Female Title/Position E-mail address Telephone number ( ) Privacy Statement (Civil Code, Section 1798 et seq.) All information requested on the application, the disclosure statement, and the provider agreement is mandatory with the exception of the social security number for any person other than the person or entity for whom an IRS Form 1099 must be provided by the Department pursuant to 26 USC 6041. This information is required by the Department of Health Care Services, Provider Enrollment Division, by the authority of Welfare and Institutions Code, Section 14043.2(a). The consequences of not supplying the mandatory information requested are denial of enrollment as a Medi-Cal provider or denial of continued enrollment as a provider and deactivation of all provider numbers used by the provider to obtain reimbursement from the Medi-Cal program. The consequence of not supplying the voluntary social security number information requested is delay in the application process while other documentation is used to verify the information supplied. Any information provided will be used to verify eligibility to participate as a provider in the Medi-Cal program. Any information may also be provided to the State Controller’s Office, the California Department of Justice, the Department of Consumer Affairs, the Department of Corporations, or other state or local agencies as appropriate, fiscal intermediaries, managed care plans, the Federal Bureau of Investigation, the Internal Revenue Service, Medicare Fiscal Intermediaries, Centers for Medicare and Medicaid Services, Office of the Inspector General, Medicaid, and licensing programs in other states. For more information or access to records containing your personal information maintained by this agency, contact the Provider Enrollment Division at (916) 323-1945 or Denti-Cal at (800) 423-0507. DHCS 6203 (rev. 2/08) Page 6 of 6 American LegalNet, Inc. www.FormsWorkFlow.com