Medi-Cal Supplemental Changes Form. This is a California form and can be use in Medi Cal Statewide.
Tags: Medi-Cal Supplemental Changes, DHS-6209, California Statewide, Medi Cal
State of California—Health and Human Services Agency Department of Health Care Services EDMUND G. BROWN JR. Governor TOBY DOUGLAS Director Dear Provider: Thank you for your recent request for the Medi-Cal Supplemental Changes form (DHCS 6209, rev. 2/08). Please complete the enclosed form 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 Medi-Cal Supplemental Changes form carefully and complete each item requested. Incomplete forms 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 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. 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. 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 to PEDCorr@dhcs.ca.gov. 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 In order to submit claims electronically, providers must request a submitter number by completing a Medi-Cal Telecommunications Provider and Biller Application/Agreement (DHCS 6153, rev. 7/07), available on the Medi-Cal Web site at www.medi-cal.ca.gov. A submitter number is not transferable. A new submitter number must be obtained each time a new Medi-Cal provider number is issued by DHCS. If you have any questions about obtaining an electronic billing submitter number, call the Telephone Service Center at 1-800-541-5555 and select the option for Computer Media Claims. 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 SUPPLEMENTAL CHANGES 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. This form is a means to inform the Department of Health Care Services (DHCS) of changes to previously submitted provider information and documentation. Applicants or providers may be subject to an on-site inspection prior to enrollment. Omission of any required information or documentation on this form, including not signing the form may result in your records with Medi-Cal not being updated as requested. You must attach copies of Centers for Medicare and Medicaid Services/National Plan and Provider Enumeration System (CMS/NPPES) confirmation for any National Provider Identifier (NPI) added with this form. Any change in an NPI for an enrolled location requires that the confirmation reflect the enrolled location’s address. 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. Enter the legal provider name as listed with the Internal Revenue Service (IRS). Enter your provider number in the space provided. Enter the date you are completing the application. Provider type: Enter your provider type in one of the boxes provided. Action requested: Check the applicable action you would like made to the provider master file. “Deactivate provider number” will deactivate all enrolled locations using the provider number submitted. To deactivate an enrolled provider type or location, please attach a cover letter specifying the deactivation request. Please complete only those boxes necessary to provide the information you are adding, changing, or deleting or to complete the action requested. Be sure to complete boxes 35-40; complete number 41, if applicable. General Information 1. “Business name”—enter the name of the applicant or provider if different from legal name. If this is a fictitious business name, provide a copy of the Fictitious Business Name Statement or Fictitious Name Permit number and effective date. 2. “Business telephone number”—enter the primary business telephone number used at the business address. A beeper number, cell phone, answering service, pager, facsimile machine, biller or billing service, or answering machine shall not be used as the primary business telephone. 3. “ Pay-to address”—enter the address at which the applicant or provider wishes to receive payment. 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. An applicant or provider may assign only one pay-to-address per NPI. 4. “Mailing address”—enter the address where the applicant or provider wishes to receive general Medi-Cal correspondence including Provider Bulletins and Provider Manual updates. 5. a. Insert the Clinical Laboratory Improvement Amendment (CLIA) certificate number. Attach a legible copy of the CLIA Certificate. b. Insert the State Laboratory License/Registration number. Attach a legible copy to the application. 6. Insert any additional NPI for the business address indicated in item 4. Attach CMS/NPPES confirmation for each. Providers not eligible to receive an NPI (atypical providers) should submit a Medicare billing number. 7. Insert the Seller’s Permit number issued by the State Board of Equalization. Attach a legible copy of the Seller’s Permit. 8. Insert any local business license, certificate, or permit numbers for any city and/or county where you conduct your business activities and attach legible copies to the application. 9. a. Insert the specialty code(s) to be added or deleted, if applicable (see Physician/Nonphysician Practitioner Specialty Codes on page 11). b. Insert the taxonomy code(s) to be added or deleted from your NPI. These taxonomy codes must already be resigistered with NPPES prior to submission to Medi-Cal. Attach additional sheets if necessary. 10. For a change of ownership or control interests of less than 50 percent, list the new ownership information in this space and submit a new Medi-Cal Disclosure Statement (DHCS 6207) for all new ownership interests. If there is a cumulative DHCS 6209 (rev. 2/08) Page 1 of 11 American LegalNet, Inc. www.FormsWorkFlow.com change of 50 percent or more in the person(s) with an ownership or control interest, as defined in Section 51000.15, since the information provided in the last complete application that was approved for enrollment, a complete application package must be submitted pursuant to Title 22, California Code of Regulations, Section 51000.30(b). 11. “Hours of operation”—enter the business days and hours the provider is available for service to Medi-Cal beneficiaries. 12. Check the appropriate box indicating whether the applicant provides “custom rehabilitation equipment” and “custom rehabilitation technology services” to Medi-Cal beneficiaries. If you answer yes, check the appropriate box whether the applicant has on staff, either as an employee or independent contractor, or the applicant has a contractual relationship with, a “qualified rehabilitation professional” who was directly involved in determining the specific custom rehabilitation equipment needs of the patient and was directly involved with, or closely supervised, the final fitting and delivery of the custom rehabilitation equipment. “Custom rehabilitation equipment” means any item, piece of equipment, or product system, whether modified or customized, that is used to increase, maintain, or improve functional capabilities with respect to mobility and reduce anatomical degradation and complications of individuals with disabilities. Custom rehabilitation equipment includes, but is not limited to, nonstandard manual wheelchairs, power wheelchairs and seating systems, power scooters that are specially configured, ordered, and measured based on patient height, weight, and disability, specialized wheelchair electronics and cushions, custom bath equipment, standers, gait trainers, and specialized strollers. “Custom rehabilitation technology services” means the application of enabling technology systems designed and assembled to meet the needs of a specific person experiencing any permanent or long-term loss or abnormality of physical or anatomical structure or function with respect to mobility. These services include, but are not limited to, the evaluation of the needs of a patient with a disability, including an assessment of the patient for the purpose of ensuring that the proposed equipment is appropriate, the documentation of medical necessity, the selection, fit, customization, maintenance, assembly, repair replacement, pick up and delivery, and testing of equipment and parts, and the training of an assistant caregiver and of a patient who will use the equipment or individuals who will assist the client in using the equipment. “Qualified rehabilitation professional” means an individual to whom any one of the following applies: (a) The individual is a physical therapist licensed pursuant to the Business and Professions Code, occupational therapist licensed pursuant to the Business and Professions Code, or other qualified health care professional approved by the Department. (b) The individual is a registered member in good standing of the National Registry of Rehabilitation Technology Suppliers, or other credentialing organization recognized by the Department. (c) The individual has successfully passed one of the following credentialing examinations administered by the Rehabilitation Engineering and Assistive Technology Society of North America: (i) The Assistive Technology Supplier examination. (ii) The Assistive Technology Practitioner examination. (iii) The Rehabilitation Engineering Technologist examination. 13. Enter the change in the business activity you are adding and the licensing information, if applicable. Attach legible copies of any licenses, certificates, or permits required. If you have questions regarding the Bureau of Home Furnishings license, please call the Bureau at (916) 574-0280; or for the Home Medical Device Retailers license call the Food and Drug Branch at (916) 650-6518. To calculate percentages of business activities, refer to the Medi-Cal Durable Medical Equipment Provider Application (DHCS 6201). If deleting incontinence medical supplies, check the box. 14. Check the appropriate boxes and complete all requested information. 15. “Geographic Area(s) Served”—enter those areas in which the provider will be transporting Medi-Cal beneficiaries. Attach a copy of the city/county business license/permit with the application. If the city/county does not require a license/permit, you must attach a letter from that city/county with the application which states the city/county does not require a license/permit. It is the applicant’s or provider’s responsibility to verify with the city/county in which transportation services will be provided for vehicle and driver’s permits. If you intend to conduct business in either the City of Los Angeles or the City of San Diego, you must apply for their vehicle and driver’s permits. For more information, contacteither the City of Los Angeles Department of Transportation or the San Diego Metropolitan Transit Development Board. 16. Provide the following information and attach legible copies if applicable: Ambulance: Certificate number issued by the California Highway Patrol (CHP)—attach a legible copy of the certificate to the application Issue date DHCS 6209 (rev. 2/08) Page 2 of 11 American LegalNet, Inc. www.FormsWorkFlow.com Vehicle Identification Number (VIN) of each vehicle that will be used to transport beneficiaries Make and model of vehicle Year of vehicle License plate number of vehicle EMS verification Driver: Full legal name of driver Driver’s license number Ambulance Driver Certificate number 17. Provide the following information and attach legible copies if applicable: Aircraft: Certificate number issued by the Federal Aviation Administration (FAA)—attach a legible copy of the certificate to the application Name and address where the aircraft is hangared—This statement must also be on your company letterhead and be attached to the application EMS verification Pilot: Full legal name of pilot Pilot’s license number—the number issued by the FAA on the pilot’s license of the individual named FAA Pilot’s license for each new pilot Driver’s license or state issued identification card 18. Provide the following information and attach legible copies if applicable: Litter and/or wheelchair van: VIN of each vehicle that will be used to transport beneficiaries Photographs of vehicle (i.e., view of inside, back exit door, side exit door, and view of business name) Make and model of vehicle Year of vehicle License plate number of vehicle Driver: Full legal name of driver Driver’s license number DMV driving history printout for each driver Brake and Lamp Certificate Driver’s license for each driver Certificates for first aid and CPR for each driver DMV DL-51 form signed by a physician for each driver Standard pre-employment drug and alcohol tests lab results for each driver 19. Insert the first, middle, and last name of the pharmacist-in-charge at the business location. 20. Provide the social security number of the pharmacist-in-charge. (Optional—See Privacy Statement on page 10) 21. Insert the license number of the pharmacist-in-charge. 22. Provide the driver’s license or state-issued identification number and state of issuance of the pharmacist-in-charge. Attach a legible copy of the driver’s license or state-issued identification card to this application. 23.-28. Answer all questions as they pertain to the pharmacist-in-charge. If any answers are checked yes, list all details to include license number, dates, licensing agency, Medi-Cal provider information and numbers, etc., in number 29. 29. Provide all details to any yes answers for numbers 23–28. 30. See instructions for subparting information. 31. Check the appropriate box. 32. Provide all details regarding the addition(s) or change(s) if you answered yes to the previous question. 33. Check the appropriate box. 34. Provide all details regarding the addition(s) or change(s) if you answered yes to the previous question. (See California Code of Regulations, Title 22, sections 51000.30, 51000.40) DHCS 6209 (rev. 2/08) Page 3 of 11 American LegalNet, Inc. www.FormsWorkFlow.com 35. Printed name of provider signing this form—enter the first, middle, and last name of the provider as the sole proprietor, partner, corporate officer, or government official when applying to the Department for enrollment or continued enrollment as a provider in the Medi-Cal program. 36. Enter the date of birth of the individual named in number 35. 37. Check the gender of the individual named in number 35. 38. Provide the driver’s license or state-issued identification number and state of issuance of the individual listed in number 35. 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. 39. Provide the social security number of the individual named in number 35. Provision of the social security number is optional (see Privacy Statement on page 9). 40. An original signature of the individual listed in number 35 is required. Also provide the title of the person signing the application who is the sole proprietor, partner, corporate officer, or by an official representative of a governmental entity or nonprofit organization who has the authority to legally bind the applicant or provider. Include the city, state, and the date where and when the application was signed. See Title 22, California Code of Regulations, Section 51000.30(a)(2)(B) to determine whether you have the authority to sign this form. 41. 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. 42. To assist in the timely processing of the application package, enter the name, e-mail address, and telephone number of the individual who can be contacted by Provider Enrollment staff to answer questions regarding the application package. 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: National Provider Identifier (NPI) verification (CMS/NPPES confirmation) Fictitious Business Name Statement or Fictitious Name Permit TIN verification CLIA Certificate State Laboratory License/Registration Seller’s Permit Professional license, permit, or certificate Business license, permit, or certificate Licenses associated with business activities: Bureau of Home Furnishings License Furniture and Bedding License Furniture License Bedding License Home Medical Device Retailer License Home Medical Device Retailer Exemptee License Other licenses, certificates, permits, etc. Pharmacist-in-Charge License Pharmacist-in-Charge driver’s license or identification card Certificates for first aid and CPR for each new driver Driver’s license for each new driver DMV DL-51 form signed by a physician for each new driver Standard pre-employment drug and alcohol tests lab results for each new driver DMV driving history printout for each new driver Driver’s license or identification card of person signing application Proof of insurance Brake and Lamp Certificate FAA certificate FAA pilot’s license for each new pilot Signed Medi-Cal Disclosure Statement (DHCS 6207) Medicare enrollment verification DHCS 6209 (rev. 2/08) Page 4 of 11 American LegalNet, Inc. www.FormsWorkFlow.com State of California—Health and Human Services Agency Department of Health Care Services MEDI-CAL SUPPLEMENTAL CHANGES Important: FOR STATE USE ONLY 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 This is not the correct form for reporting a change in business address. Legal provider name (as listed with the IRS) Provider Number (NPI or Denti-Cal provider number as applicable) Date / / PROVIDER TYPE (check one) Dentist DME Laboratory Orthotic and prosthetic Pharmacy Physician Provider group Registered Dental Hygienist Alternative Practice Transportation Other provider type (please describe) ______________________________________________ ACTION REQUESTED (check all that apply) Add: Change (continued): Business activity Clinical Laboratory Improvement Amendment (CLIA) Doing-Business-As (DBA) name Licenses, permits, certificates, etc. Medical transportation vehicle, driver or pilot Seller’s Permit Medicare/Other NPI Specialty code Taxonomy Code Address and/or phone (pay-to or mailing only) List any provider numbers the change is associated with: _________________________________________________ Medical transportation vehicle, driver, pilot or geographic area served Persons with ownership or control interest less than 50 percent Pharmacist-in-charge Managing employee Hours of operation Business activities Doing-Business As (DBA) name Other information previously submitted in an application package Delete: Clinical Laboratory Improvement Amendment (CLIA) Medical transportation vehicle, driver, or pilot Specialty code Miscellaneous: PIN (Provider Identification Number) Issuance (new PIN) Confirmation (existing PIN) Deactivate provider number _________________________ Deactivate provider type/location (attach letter specifying change) Change: NPI assigned to one or more locations--see page 10. Complete only the boxes specific to the action requested. Complete boxes 35–40. Complete box 41, if applicable. GENERAL INFORMATION 1. Business name, if different 2. Business telephone number ( Is this a fictitious business name? If yes, list the Fictitious Business Name Statement/Permit number ) Effective date / Yes / No (Attach a legible copy of the recorded/stamped Fictitious Business Name Statement or Fictitious Name Permit, if applicable.) 3. Pay-to address (number, street, P.O. Box number) City State Nine-digit ZIP code 4. Mailing address (number, street, P.O. Box number) City State Nine-digit ZIP code 5.a. Clinical Laboratory Improvement Amendment (CLIA) certificate number (attach a legible copy) 7. Seller’s Permit number (attach a legible copy) 5.b. State Laboratory License/Registration number (attach a legible copy) 8. Any local business license, permit or certificate numbers (attach a legible copy) 6. Medicare/Other NPI/Medicare Billing Number (see instructions) 9.a. Specialty code(s), if applicable Add: _______________ DHCS 6209 (rev. 2/08) Delete: _______________ Page 5 of 11 American LegalNet, Inc. www.FormsWorkFlow.com 9.b. Taxonomy Codes (attach additional sheets if necessary) Add: ______________________________________ Delete: ______________________________________ ______________________________________ ______________________________________ _______________________________________ ______________________________________ 10. Change of Ownership or Control Interests—Not to exceed 49% cumulative changes since last complete application approved for this provider number. Type of entity (check one) Sole proprietor Limited liability company Partnership (Attach legible copy of agreement) Government Corporation Nonprofit Other (describe) ____________________________________________________ Are you adding owners, managing employees, or change in interest? If so, please provide the following information: Name Title Ownership percentage Name Title Ownership percentage Name Title Ownership percentage Name Title Ownership percentage Name Title Ownership percentage Name Title Ownership percentage Name Title Ownership percentage Name Title Ownership percentage Name Title Ownership percentage Name Title Ownership percentage Are you deleting owners? If so, please provide the following information: 11. Change in hours of operation The business days and hours of operation are: Days: _____________________________________ Hours:___________________________ FOR DURABLE MEDICAL EQUIPMENT AND PHARMACY PROVIDERS ONLY 12. Do you provide custom rehabilitation equipment and custom rehabilitation technology services to Medi-Cal beneficiaries? Yes No If yes. do you have on staff, either as an employee or independent contractor, or do you have a contractual relationship with, a qualified rehabilitation professional who was directly involved in determining the specific custom rehabilitation equipment needs of the patient and was directly involved with, or closely supervised, the final fitting and delivery of the custom rehabilitation equipment? Yes No 13. Change in Business Activities Add (please describe activities and percentages to equal 100%. Attach additional page.) _____________________________________ If you are adding a business activity which requires any type of license, certificate, permit, etc., please list the information here and attach a legible copy of the license to this application: Bureau of Home Furnishings license (see instructions): Furniture and Bedding or Furniture Retailer License number (attach a legible copy): ____________________ (If you are a DME provider and are renting beds, your license must bear a Registry number.) / / Issuance date: ___________________________________ Registry number: _______________ / / Expiration date: _______________________ Home Medical Device Retailer License (attach a legible copy): _____________________________________ / / Issuance date: ___________________________________ / / Expiration date: _______________________ Home Medical Device Retailer Exemptee License (attach a legible copy): _____________________________ / / Issuance date: ___________________________________ / / Expiration date: _______________________ Other license, certificate, permit, etc. (attach a legible copy): _______________________________________ Delete incontinence medical supplies Page 6 of 11 DHCS 6209 (rev. 2/08) American LegalNet, Inc. www.FormsWorkFlow.com 14. Do you sell, rent, or lease durable medical equipment, incontinence medical supplies and/or supply items? Yes Yes If yes, do you have a retail business open and available to the general public which meets all local laws and ordinances regarding business licensing and operation and is readily identifiable? No No If no, please explain Are your equipment and/or supplies: A. In stock on the premises, or B. In a warehouse under the applicant’s or provider’s direct control. Business days and hours of operation: Days: ____________________________ Hours: ________________________________ If B is checked, provide the following information for the warehouse: Address (number, street) City State Nine-digit ZIP code Who holds an ownership interest in the warehouse? (Use additional sheets if necessary.) Name Telephone number ( Address (number, street) City ) State Nine-digit ZIP code FOR TRANSPORTATION PROVIDERS ONLY 15. Geographic area(s) served (list city/county—attach copy of permit) __________________________________ __________________________________ _________________________________ __________________________________ __________________________________ _________________________________ 16. Ambulance and Driver Information—see instructions (attach a separate sheet, if necessary) Ambulance Information CHP Certificate Number Issue Date / Year License Number Add Delete ( ) ( ) / / Make and Model of Vehicle / / Vehicle Identification Number(s) / Ensure legible copies of the following documents for each ambulance are attached to the application: CHP 301 certificate EMS Certificate, local CHP 360A Ambulance license Driver Information (attach a legible copy(ies) of driver’s license(s) and DMV DL-51(s)) Driver’s Name(s) Driver’s License Number Year of Expiration DMV DL-51 (Driver’s Only) Add Delete Effective Date Expiration Date ( ) ( ) / / / / / / / / / / / / 17. Aircraft and Pilot Information—see instructions (attach a separate sheet, if necessary) Aircraft Information FAA Certificate Number Add Delete ( ) ( ) Name and Address Where Aircraft is Hangared Ensure a legible copy of the following document for each aircraft is attached to the application: FAA Certificate EMS Certificate Pilot information (attach a legible copy(ies) of pilot’s license(s) Pilot’s Name(s) Driver’s License Number or State Issued Identification Number Pilot’s License Number Year of Expiration Add Delete ( ) ( ) ✔ DHCS 6209 (rev. 2/08) Page 7 of 11 American LegalNet, Inc. www.FormsWorkFlow.com Ensure a legible copy of the following documents are attached to the application (as applicable): FAA pilot’s license for each pilot Driver’s license or state issued identification card 18. Litter and/or Wheelchair Van/Driver Information—see instructions (attach a separate sheet, if necessary) Vehicle Information Vehicle Identification Number(s) Make and Model of Vehicle Year Ensure legible copies of the following documents for each vehicle are attached to the application: DMV vehicle registration Proof of vehicle insurance Brake and Lamp Certificate Add Delete ( ) ( ) License Number Special vehicle permit (if applicable) Driver Information Name Add Delete ( ) ( ) California Driver’s License Number Ensure legible copies of the following documents for each new driver are attached to the application: DMV driving record printout California Driver’s License DMV DL-51 form signed by a physician Certificates for first aid and CPR Special driver permit (if applicable) Standard pre-employment drug test (which lists the drugs tested for) and alcohol test lab results FOR PHARMACIES ONLY NEW PHARMACIST-IN-CHARGE (PIC) 19. Printed name (last) (first) (middle) 20. PIC social security number (Optional—Privacy Statement on page 9.) 21. PIC license number (attach a legible copy of license and renewal, if applicable) _____ _____ _____ — _____ _____ — _____ _____ _____ _____ 22. Driver’s license or state-issued identification card number (attach a copy) State of issuance If you answer yes to questions 23–28, give details in number 29 (see instructions) Yes No 23. Has the PIC’s individual license, certificate, or other approval to provide health care ever been suspended or revoked? 24. Has the PIC’s individual license, certificate, or other approval to provide health care ever been lost or surrendered? 25. Does the PIC have an ownership or control interest in any other medical or Medi-Cal health care provider? 26. Has the PIC previously participated in the Medi-Cal program? 27. Has the PIC ever participated in another State’s Medicaid program? 28. Has the PIC ever been suspended from a Medicare or Medicaid program? 29. Details for questions 23–28 (see instructions): DHCS 6209 (rev. 2/08) Page 8 of 11 American LegalNet, Inc. www.FormsWorkFlow.com NATIONAL PROVIDER IDENTIFIER (NPI) SUBPARTING General Subparting Instructions The table below is intended for applicants and providers who have subparted and wish to change an NPI assigned to one or more Medi-Cal enrolled locations. An applicant or provider must determine whether or not to subpart based on their business practices, billing practices and federal requirements including the NPI Final Rule. A subpart is a component of a health care organizational provider, such as a provider group, that is not a person. A subpart furnishes health care and might: • Conduct standard transactions • Be required by Federal regulations to have a Federal billing number (e.g., Medicare billing number) • Be certified/licensed separately from the covered organization • Have a location different from the covered organization • Be a member of a chain • Be a DMEPOS provider If you are an individual sole proprietor (unincorporated) health care provider such as a physician, dentist, nurse, chiropractor, etc., you do not qualify to subpart. When you receive your NPI you will be identified with an Entity Type Code 1 (Health care providers who are individual human beings, including sole proprietors.). If you are an organization, you may subpart. When you receive your NPI you will be identified with an Entity Type Code 2 (Health care provider who is other than an individual human being). Examples of organizations are hospitals; individuals who have incorporated, home health agencies; clinics; nursing homes; residential treatment centers; laboratories; emergency and nonemergency medical transportation companies; group practices; suppliers of durable medical equipment, prosthetics and orthotics providers; and pharmacies. For additional information, please see the Centers for Medicare and Medicaid Services website at: https://www.cms.hhs.gov/NationalProvIdentStand/ for comprehensive information regarding subparting and general NPI implementation. 30. Subpart Designation Table “Enrolled business location”—You must be currently enrolled at this location. “NPI currently on file”—Indicate the NPI assigned to the enrolled business location at the time this form is submitted. “New NPI being assigned to the location”—Indicate the new NPI you wish to have assigned to the enrolled business location listed. Enrolled Business Location Number and street City Zip Code NPI currently on file New NPI being assigned Attach additional sheets if necessary. Remember to attach verification of any new NPIs assigned. Any change in an NPI for an enrolled location requires that the confirmation reflect the enrolled location’s address. DHCS 6209 (rev. 2/08) Page 9 of 11 American LegalNet, Inc. www.FormsWorkFlow.com OTHER INFORMATION 31. Are you reporting any addition(s) or change(s) in information to a pending application? Yes No 32. If you answer yes to the prior question, please explain: ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ 33. Are you reporting any addition(s) or change(s) in information submitted in a prior application package other than information covered elsewhere in this form that does not require the submission of a new application package? Yes No 34. If you answer yes to the prior question, please explain: ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ INFORMATION ABOUT PROVIDER 35. Printed name (last) (first) (middle) 36. Date of birth / 38. Driver’s license or state-issued identification number and state of issuance (attach a legible copy) 37. Gender Male / Female 39. Social security number (Optional—see Privacy Statement below.) _____ _____ _____ — _____ _____ — _____ _____ _____ _____ 40. 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) 41. Notary Public—Please see instructions under number 41 for who must have their form signed by a Notary Public in the form specified by Section 1189 of the Civil Code. 42. Contact Person’s Information Check here if you are the same person identified in item 35. 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 and 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 6209 (rev. 2/08) Page 10 of 11 American LegalNet, Inc. www.FormsWorkFlow.com PHYSICIAN/NONPHYSICIAN MEDICAL PRACTITIONER SPECIALTY CODES Specialty Allergy Anesthesiology Aviation (MD Only) Cardiovascular Disease (MD Only) Clinics-Mixed Specialty Dermatology Emergency Medicine (Urgent Care) Endocrinology Family Practice-House Calls Gastroenterology (MD Only) General Practice (General Medicine) General Surgery Geriatrics Hand Surgery Hematology Infectious Disease Internal Medicine Miscellaneous Neoplastic Diseases Nephrology (Renal-Kidney) Neurological Surgery Neurology (MD Only) Neurology-Child Nuclear Medicine Obstetrics Obstetrics-Gynecology (MD Only) Neonatal Oncology Ophthalmology Orthopedic Surgery Otology, Laryngology, Rhinology (ENT) Pathology (MD Only) Pathology-Forensic Pediatric Allergy Pediatric Cardiology (MD Only) DHCS 6209 (rev. 2/08) Code 03 05 11 06 70 07 66 67 08 10 01 02 38 46 68 77 41 47 78 45 14 13 79 42 15 16 78 18 20 04 22 90 43 35 Specialty Code 40 91 25 24 28 36 26 44 29 30 83 84 89 33 99 34 Pediatrics Pharmacology-Clinical Physical Medicine & Rehabilitation Plastic Surgery Proctology (Colon & Rectal) Psychiatry Psychiatry-Child Public Health Pulmonary Diseases (MD only) Radiology Rheumatology Surgery-Head & Neck Surgery-Traumatic Thoracic Surgery Unknown Urology, Urological Surgery Osteopaths Only Gynecology Manipulative Therapy Ophthalmology, Otolaryngology, Rhinology Pathologic Anatomy; Clinical Pathology Peripheral Vascular Disease or Surgery Psychiatry Neurology 09 12 17 21 23 27 Peripheral Vascular Disease or Surgery Radiation Therapy Roentgenology, Radiology 23 32 31 Nonphysician Medical Practitioner Nurse Practitioner Physician Assistant Nurse Midwife 2 3 4 Page 11 of 11 American LegalNet, Inc. www.FormsWorkFlow.com