Form DHCS6216 "Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers" - California

What Is Form DHCS6216?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2020;
  • The latest edition provided by the California Department of Health Care Services;
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  • Fill out the form in our online filing application.

Download a fillable version of Form DHCS6216 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form DHCS6216 "Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers" - California

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State of California—Health and Human Services Agency
Department of Health Care Services
WILL LIGHTBOURNE
GAVIN NEWSOM
DIRECTOR
GOVERNOR
Dear Applicant:
Effective November 4, 2016, a complete Rendering Provider application includes the Medi-Cal
Rendering Provider/Group/Affiliation/Disaffiliation Form (DHCS 4029, Rev. 12/16). DHCS 4029 is
available at files.medi-cal.ca.gov/pubsdoco/forms.asp and must be submitted with the Medi-Cal
Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental
Providers (DHCS 6216, Rev. 5/17).
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 Centers
for Medicare & Medicaid Services (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 Department of Health Care Services (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 (DHCS 6209, Rev. 2/18). 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 California Code of Regulations
(CCR), Title 22, 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 (DHCS 6217, Rev. 5/17).
Provider Enrollment Division
MS 4704
P.O. Box 997412, Sacramento, CA 95899-7412
Internet Address: www.dhcs.ca.gov/provgovpart/Pages/PED.aspx
State of California—Health and Human Services Agency
Department of Health Care Services
WILL LIGHTBOURNE
GAVIN NEWSOM
DIRECTOR
GOVERNOR
Dear Applicant:
Effective November 4, 2016, a complete Rendering Provider application includes the Medi-Cal
Rendering Provider/Group/Affiliation/Disaffiliation Form (DHCS 4029, Rev. 12/16). DHCS 4029 is
available at files.medi-cal.ca.gov/pubsdoco/forms.asp and must be submitted with the Medi-Cal
Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental
Providers (DHCS 6216, Rev. 5/17).
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 Centers
for Medicare & Medicaid Services (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 Department of Health Care Services (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 (DHCS 6209, Rev. 2/18). 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 California Code of Regulations
(CCR), Title 22, 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 (DHCS 6217, Rev. 5/17).
Provider Enrollment Division
MS 4704
P.O. Box 997412, Sacramento, CA 95899-7412
Internet Address: www.dhcs.ca.gov/provgovpart/Pages/PED.aspx
Enrollment forms are available at www.medi-cal.ca.gov or by contacting the Telephone Service Center
(TSC) at 1-800-541-5555. For more information about the forms and the regulatory requirements for
participation in the Medi-Cal program, please visit our website 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 on the previous page 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. 3/17),
available on the Medi-Cal Provider website at www.medi-cal.ca.gov, under “References,” “Forms” and
then “Billing.”
Provider Enrollment Division
Enclosures
(Rev. 9/20)
State of California
Department of Health Care Services
Health and Human Services Agency
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 questions, 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
signature in ink on 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.
DHCS 6216 (Rev. 5/17)
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State of California
Department of Health Care Services
Health and Human Services Agency
6. Enter the social security number of the individual named in number 1. (This field is mandatory-see
Privacy Statement on Page 9)
7. Enter the driver’s license or state-issued identification number and state of issuance of the individual
named in number 1. 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.
8. Enter the license, certificate number, or other permit or approval to provide health care, of the
applicant. Attach a legible copy of the license, certificate, permit, or approval. Enter the effective date
of the license, certificate number, or other permit or approval. Enter the expiration date of the license,
certificate number, or other permit or approval. If a physician or dentist, list the specialty(ies) and
indicate if board-certified or board-eligible.
9. “Business address”—enter the actual business location including the street number and name, room
or suite number or letter, city, county, state, and nine-digit ZIP code. A post office box or commercial
box is not acceptable.
10. “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.
11. “Contact person”—enter the name of the person who can be contacted regarding the application
package.
12. “Contact telephone number”—enter the phone number of the contact person.
13. “Contact e-mail address”—enter the e-mail address of the contact person.
14. “Provider number of Group being joined”—enter the NPI or Denti-Cal provider number of the Medi-
Cal Group Provider that the individual named in number 1 is joining.
15. “Proof of professional liability insurance”—enter the name of the insurance company, insurance
policy number, date policy issued, expiration date of policy, insurance agent’s name, telephone
number of the insurance agent, fax number of the insurance agent and email address of the insurance
agent. You must also attach a copy of your certificate of insurance to the application.
Disclosure Information
1. Check the appropriate boxes and provide the date of conviction if applicable.
2. Check the appropriate boxes and provide the date of final judgment if applicable.
3. Check the appropriate boxes and provide the date of settlement if applicable.
4. Check the appropriate box and list all provider numbers, if appropriate, as well as the state(s) and
name(s) applicant or provider used when participating in another state Medicaid program and all
applicable provider numbers. If you cannot provide the numbers, please explain.
5. Check the appropriate box and, if applicable, provide Medicare, Medicaid, and/or Medi-Cal NPIs or
provider number(s), the effective date(s) of suspension(s), and date(s) of reinstatement.
6. Check the appropriate box and, if applicable, list the state(s) where applicant’s or provider’s license,
certificate, or other approval to provide health care was suspended or revoked and the effective
dates of those actions. Attach the written confirmation that professional privileges have been
restored.
7. Check the appropriate box and, if applicable, list the state(s) where the applicant’s or provider’s
license, certificate, or other approval to provide health care was lost or surrendered while a
DHCS 6216 (Rev. 5/17)
Page 2 of 9
State of California
Department of Health Care Services
Health and Human Services Agency
disciplinary hearing was pending and the effective dates of those actions. Attach a
written confirmation from the licensing authority that professional privileges have been restored.
8. Check the appropriate box and, if applicable, list the state(s) where the applicant’s or provider’s
license, certificate, or other approval to provide health care was disciplined by a licensing authority,
actions taken, and the effective dates of those actions. Attach a written confirmation from
the licensing authority decision(s) including any terms and conditions for each decision.
9. List below fines/debts due and owing by applicant/provider to any federal, state, or local government
that relate to Medicare, Medicaid, and all other federal and state health care programs that have
not been paid and what arrangements have been made to fulfill the obligation(s). Submit copies of
all documents pertaining to the arrangement(s) including terms and conditions. If not
applicable, check N/A box.
10. To assist in the timely processing of the application package, enter the name, title/position,
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.
Provider Agreement
Print name of the applicant signing the application. An original signature of the individual is required.
Include the city, state, and the date where and when the application was signed. See CCR, Title 22,
Section 51000.30(a)(2)(B) to determine whether you have the authority to sign this application.
 Remember to attach a legible copy of the following, if applicable:
Driver’s license or state-issued identification card
License certificate
Verification of reinstatement
Written confirmation from licensing authority that your professional privileges have been restored
Copies of payment arrangement documents
Notary Public Certificate of acknowledgment
Certificate of insurance (malpractice)
Drug Enforcement Agency (DEA) certificate
Anesthesia Permit
Conscious Sedation Permit
National Provider Identifier verification (CMS/NPPES confirmation)
DHCS 6216 (Rev. 5/17)
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