State of California Health and Human Services Agency Department of Health Care Services JENNIFER KENT GAVIN NEWSOM D IRECTOR G OVERNOR Provider Enrollment Division MS 4704 P.O. Box 997412, Sacramento, CA 95899 - 7412 Internet Address: www.dhcs.ca.gov /provgovpart/Pages/PED.aspx Dear Applicant: **Effective November 4, 2016, a complete Rendering Provider application includes the Medi - Cal Rendering Provider/Group/Affiliation/Disaffiliation F orm (DHCS 4029 , Rev. 12/16 ). DHCS 4029 is available at files.medi - cal.ca.gov/pubsdoco/forms.asp and must be submitted with the Medi - Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers (DHCS 6216 , Rev. 5/17) .** Thank you for your recent inquiry regarding participation in the Medi - Cal program. Please complete t he 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, C A 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 Centers for Medicare & Medicaid Services ( 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, unique Medi - Cal provider number once the application is approved. It is your responsibility to report to the Department of Health Care Service s (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 form (DHCS 6209, Rev. 2/18 ). However, you must complete a new application package i f you are reporting a change of ownership of 50 percent or mor e, a change of business address or one of the other changes identified in California Code of Regulations (CCR), Title 22, Section 51000.30, subsections (a) through (b). If you are planning to s ell 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 (DHCS 6217 , Rev. 5/17 ). American LegalNet, Inc. www.FormsWorkFlow.com Enrollment forms are available at www.medi - cal.ca.gov or by contacting the Telephone Service Center (TSC) at 1 - 800 - 541 - 5555. For more information about the forms and the regulatory requirements for participation in the Medi - Cal program, please visit our website at www.medi - cal.ca.gov and click the 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 on the previous page 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. 3/17 ), available on the Medi - Cal website at w ww.medi - cal.ca.gov References and then Provider Enrollment Division Enclosures (Rev. 4/19 ) American LegalNet, Inc. www.FormsWorkFlow.com State of California Department of Health Care Services Health and Human Services Agency DHCS 6216 (Rev. 5/17) Page 1 of 9 INSTRUCTIONS FOR COMPLETION OF THE MEDI-CAL RENDERING PROVIDER APPLICATION/DISCLOSURE STATEMENT/AGREEMENT FOR PHYSICIAN/ALLIED/DENTAL PROVIDERS 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 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 rendering 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. Additional information can be found on the following Medi-Cal Website (www.medi-cal.ca.gov) by clicking the 223Provider Enrollment224 link. Omission of any information on this form, or the failure to provide required documentation or signature in ink on any of these documents may result in denial of the application as provided 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. To request consideration for Preferred Provider Status, check the box and include all required documentation pursuant to the Preferred Provider Bulletin dated February 2004, which is available on the 223Provider Enrollment Division224 (PED) page of the Medi-Cal Website (www.medi-cal.ca.gov). Only those complete applications submitted with all qualifying documentation included will be processed with a preferred provider status. Action requested (check all that apply). Enter the date you are completing the application. 223New rendering physician/allied/dental provider224227The applicant is not currently enrolled with the Medi-Cal program as a provider with an active provider number. National Provider Identifier227enter your NPI. If the individual identified in item 1 has more than one, enter the NPI you wish to use for enrollment as a rendering provider. Provider Type: Check the appropriate provider type box for which you are applying to render services for the Medi-Cal program. 1.223Legal name224 227enter the name listed with the Internal Revenue Service (IRS).2.Enter the date of birth of the individual named in number 1.3.Enter the gender of the individual named in number 1.4.223Residence address224227enter the residence address of the individual listed in number 1.5.223Mailing address224227enter the address where correspondence may be sent to the individual listed innumber 1. American LegalNet, Inc. www.FormsWorkFlow.com State of California Department of Health Care Services Health and Human Services Agency DHCS 6216 (Rev. 5/17) Page 2 of 9 6.Enter the social security number of the individual named in number 1. (This field is mandatory-seePrivacy Statement on Page 9)7.Enter the driver222s license or state-issued identification number and state of issuance of the individualnamed in number 1. Attach a legible copy to the application. The driver222s license or state-issuedidentification number shall be issued within the 50 United States or the District of Columbia.8.Enter the license, certificate number, or other permit or approval to provide health care, of theapplicant. Attach a legible copy of the license, certificate, permit, or approval. Enter the effective dateof the license, certificate number, or other permit or approval. Enter the expiration date of the license,certificate number, or other permit or approval. If a physician or dentist, list the specialty(ies) andindicate if board-certified or board-eligible.9.223Business address224227enter the actual business location including the street number and name, roomor suite number or letter, city, county, state, and nine-digit ZIP code. A post office box or commercialbox is not acceptable.10. 223Business telephone number224227enter the primary busin