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Application For Medi-Cal Certification As A Primary Care Clinic Provider HS 269 - California

Application For Medi-Cal Certification As A Primary Care Clinic Provider Form. This is a California form and can be used in Licensing And Certification Department Of Health And Human Services Statewide .
 Fillable pdf Last Modified 9/24/2008
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State of California--Health and Human Services Agency California D epartment of Public Health APPLICATION FOR MEDI-CAL CERTIFICATION AS A PRIMARY CARE CLINIC PROVIDER Initial application 1. Clinic name (dba) Change of ownership application Update Street address (number, street) P.O. Box City State ZIP code Telephone number Fax number Federal EIN number Medi-Cal provider number(s) ( ) ( ) 2. If this is an intermittent clinic, what is the name (dba) and address of the parent clinic: Name Street address (number, street) P.O. Box City State ZIP code Telephone number Fax number Federal EIN number Medi-Cal provider number(s) ( 3. ) ( ) Legal name of entity (corporation) owning clinic Street address (number, street) P.O. Box City State ZIP code Telephone number Fax number Federal EIN number Medi-Cal provider number(s) ( ) ( ) NOTE: The entity must complete this form for each clinic owned and/or operated in California. Questions 4 through 8 apply to the clinic listed in number 1 above. 4. Specific type of service, advice, and/or treatment to be provided: 5. Source of funds and income for clinic operation: 6. Check each day of the week clinic is open: 7. Enter the number of hours the clinic is open under each day of the week checked: 8. Enter the number of hours patients are seen under each day of the week checked: S M T W Th F S I declare under penalty of perjury that the statements on this document are correct to my knowledge. Signature Date Print name Title HS 269 (2/08) American LegalNet, Inc. www.FormsWorkflow.com
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