California
Statewide
Medi Cal
Last updated: 11/17/2021
Medi-Cal Provider Application {DSH-6204}
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Description
DHCS 6204, MEDI-CAL PROVIDER APPLICATION, This form is part of an application for enrollment or continued enrollment as a 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. In addition to this form and requested documentation, a MEDI-CAL DISCLOSURE STATEMENT (DHCS 6207) and a MEDI-CAL PROVIDER AGREEMENT (DHCS 6208) must also be completed for enrollment or continued enrollment. www.FormsWorkflow.com
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