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Medi-Cal Rendering Provider Application-Disclosure Statement-Agreement For Physician-Allied-Dental Providers DHCS 6216 - California
| Medi-Cal Rendering Provider Application-Disclosure Statement-Agreement For Physician-Allied-Dental Providers Form. This is a California form and can be used in Medi Cal Statewide . |
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State of California--Health and Human Services Agency Department of Health Care Services TOBY DOUGLAS Director EDMUND G. BROWN JR. Governor 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 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 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 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 "Provider Enrollment" link. Omission of any information on this form, or the failure to provide required documentation or sign 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 "Provider Enrollment Division" (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. "New rendering physician/allied/dental provider"--The applicant is not currently enrolled with the Medi-Cal program as a provider with an active provider number. National Provider Identifier--enter 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. "Legal name"--enter 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. "Residence address"--enter the residence address of the individual listed in number 1. 5. "Mailing address"--enter the address where correspondence may be sent to the individual listed in number 1. 6. Enter the social security number of the individual named in number 1. (This field is optional--see Privacy Statement on page 5) 7. Enter t
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