State of California Health and Human Services Agency Department of Health Care Services JENNIFER K ENT GAVIN NEWSOM DIRECTOR GOVERNOR Provider Enrollment Division MS 4704 P.O. Box 997412, Sacramento, CA 95899 - 7412 Phone: (916) 323 - 1945 Internet Address: www.dhcs.ca.gov /provgovpart/Pages/PED.aspx Dear Provider : Thank you for your recent request for the Medi - Cal Supplemental Changes form (DHCS 6209, R ev. 2 / 1 8 ). Please complete the enclosed form and return it to: Department of Health Care Services Provider Enrollment Division MS 4704 P.O. Box 997 412 Sacramento, CA 95899 - 7412 Please read all the instructions included in the DHCS 6209 form carefully and complete each item requested. Incomplete forms will be returned. PLEASE NOTE: Applicants and providers are required to submit their National Pro vider 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 i n 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 i s 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 DHCS 6209 form . However, you must complete a new application package if you are re porting a change of ownership of 50 percent or more, 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 sell your bu siness or buy an existing business, you may find it helpful to refer to the Provider Enrollment page of the Medi - Cal website 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 form (DHCS 6217, Rev. 5/17) . If you have any additional enrollment questions, please contac t the Provider Enrollment Message Center at (916) 323 - 1945, or submit your question(s) to the address below or via email at PEDCorr@dhcs.ca.gov . American LegalNet, Inc. www.FormsWorkFlow.com Please visit the Medi - Cal website at www.medi - cal.ca.gov for information on submitting claims electronically. 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 t he Telephone Service Cen ter (TSC) at 1 - 800 - 541 - 5555 and select the option for Computer Media Claims (CMC) . Provider Enrollment Division Enclosures (Rev. 6 /18 ) American LegalNet, Inc. www.FormsWorkFlow.com DHCS 6209 (Rev. 2/18) Page 1 of 19 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 any 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 location222s 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 (NPI or Denti-Cal provider number as applicable) 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. 223Deactivate provider number224 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 40-45; complete box 46, if applicable. GENERAL INFORMATION 1. 223Business name224 226 enter the name of the applicant or provider if different than 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. 223Business telephone number224 226 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. 223Pay-to address224 226 enter the address at which the applicant or provider wishes to receive payment. The pay-to address should include, as applicable, the number, street name, room, suite number or letter, P.O. box number, city, state, and nine-digit ZIP code. An applicant or provider may assign only one pay-to-address per NPI. Please note, substance use disorder clinics may not use the DHCS 6209 to update their 223Pay-to Address.224 4. 223Mailing address224 226 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. American LegalNet, Inc. www.FormsWorkFlow.com DHCS 6209 (Rev. 2/18) Page 2 of 19 6. Insert any additional NPI for the entity indicated in number 1. Attach CMS/NPPES confirmation for each. Providers not eligible to receive an NPI (atypical providers) must submit a Medicare billing number. 7. Insert the Seller222s Permit number issued by the State Board of Equalization. Attach a legible copy of the Seller222s Permit. 8. Insert any local business license, permit, or certificate 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/Non-Physician Practitioner Specialty Codes on page 19. b. Insert the taxonomy code(s) to be added or deleted from your NPI. These taxonomy codes must already be registered with NPPES prior to submission to Medi-Cal. Attach additional sheets if necessary. CHANGE OF OWNERSHIP OR CONTROL INTERESTS 10. For a change of ownership or control interests of less than 50 percent, list the new ownership information in this space and submit Sections III and IV of the Medi-Cal Disclosure Statement (DHCS 6207) for all new owners, managing employees, or control interests. If there is a cumulative 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 California Code of Regulations, Title 22, Section