Form DHCS4029 "Medi-Cal Rendering Provider/Group Affiliation/Disaffiliation Form" - California

What Is Form DHCS4029?

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 December 1, 2016;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHCS4029 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 DHCS4029 "Medi-Cal Rendering Provider/Group Affiliation/Disaffiliation Form" - California

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State of California
Department of Health Care Services
Health and Human Services Agency
INSTRUCTIONS FOR COMPLETION OF THE
MEDI-CAL RENDERING PROVIDER/GROUP AFFILIATION/DISAFFILIATION FORM
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 for the purpose of affiliating or disaffiliating rendering providers to billing group
enrollments.
Omission of any information on this form, including not signing the form, may result in your records
with Medi-Cal not being updated as requested.
Action requested. Enter the date you are completing the form.
A. Affiliate Identification Information
1. “Legal name of rendering provider”—enter the name as listed with the Internal Revenue Service
(IRS).
2. “ Rendering National Provider Identifier” – enter the rendering affiliate’s NPI.
3. “Legal name of group provider” – enter the name of the billing group as reported to the IRS.
4. “Group National Provider Identifier” – enter the billing group’s NPI.
5. - 8. Enter the actual enrolled service location(s) at which the rendering provider provides services
for the group provider listed in item 3. Include the street name and number, room/suite
number or letter, city, state, and nine-digit ZIP code. A post office box or commercial box is
not acceptable.
B. Rendering Provider Signature
9. Legal name of rendering affiliate. An original signature is required.
Stamped, faxed, and/or photocopied signatures are not acceptable. Rendering provider must
also attach a legible copy of their driver’s license or state-issued identification card.
C. Group Provider Signature
10. Legal name of individual who is the sole proprietor, partner, corporate officer, or an official
representative of a governmental entity or nonprofit organization who has the authority to legally
bind the group provider listed, including a delegated official, as defined in the Regulatory Provider
Bulletin, Requirements and Procedures for Medi-Cal Provider Groups Designating Delegated
Officials for the Sole Purpose of Signing Affiliation Forms. An original signature is required.
Stamped, faxed, and/or photocopied signatures are not acceptable.
11. Location of signature and notarization.
12. This form must be notarized by a Notary Public except for those applicants and providers licensed
pursuant to Business and Professions Code, Division 2, beginning with Section 500, the
Osteopathic Initiative Act, or the Chiropractic Initiative Act.
D. Contact Person’s Information
13. “Contact person”—enter the name, title/position, contact telephone number, and contact e-mail
address of the person who can be contacted regarding this form.
DHCS 4029 (Rev. 12/16)
Page 1 of 4
State of California
Department of Health Care Services
Health and Human Services Agency
INSTRUCTIONS FOR COMPLETION OF THE
MEDI-CAL RENDERING PROVIDER/GROUP AFFILIATION/DISAFFILIATION FORM
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 for the purpose of affiliating or disaffiliating rendering providers to billing group
enrollments.
Omission of any information on this form, including not signing the form, may result in your records
with Medi-Cal not being updated as requested.
Action requested. Enter the date you are completing the form.
A. Affiliate Identification Information
1. “Legal name of rendering provider”—enter the name as listed with the Internal Revenue Service
(IRS).
2. “ Rendering National Provider Identifier” – enter the rendering affiliate’s NPI.
3. “Legal name of group provider” – enter the name of the billing group as reported to the IRS.
4. “Group National Provider Identifier” – enter the billing group’s NPI.
5. - 8. Enter the actual enrolled service location(s) at which the rendering provider provides services
for the group provider listed in item 3. Include the street name and number, room/suite
number or letter, city, state, and nine-digit ZIP code. A post office box or commercial box is
not acceptable.
B. Rendering Provider Signature
9. Legal name of rendering affiliate. An original signature is required.
Stamped, faxed, and/or photocopied signatures are not acceptable. Rendering provider must
also attach a legible copy of their driver’s license or state-issued identification card.
C. Group Provider Signature
10. Legal name of individual who is the sole proprietor, partner, corporate officer, or an official
representative of a governmental entity or nonprofit organization who has the authority to legally
bind the group provider listed, including a delegated official, as defined in the Regulatory Provider
Bulletin, Requirements and Procedures for Medi-Cal Provider Groups Designating Delegated
Officials for the Sole Purpose of Signing Affiliation Forms. An original signature is required.
Stamped, faxed, and/or photocopied signatures are not acceptable.
11. Location of signature and notarization.
12. This form must be notarized by a Notary Public except for those applicants and providers licensed
pursuant to Business and Professions Code, Division 2, beginning with Section 500, the
Osteopathic Initiative Act, or the Chiropractic Initiative Act.
D. Contact Person’s Information
13. “Contact person”—enter the name, title/position, contact telephone number, and contact e-mail
address of the person who can be contacted regarding this form.
DHCS 4029 (Rev. 12/16)
Page 1 of 4
State of California
Department of Health Care Services
Health and Human Services Agency
MEDI-CAL RENDERING PROVIDER/GROUP
AFFILIATION/DISAFFILIATION FORM
For State Use Only
Important:
• Read all instructions before completing the form.
• Type or print clearly, in ink.
• If you must make corrections, please line through, date and initial in ink.
• For Medi-Cal return completed forms to:
Department of Health Care Services
Provider Enrollment Division
MS 4704
P.O. Box 997412
Sacramento, CA 95899-7412
(916) 323-1945
• Do not use staples on this form or on any attachments.
• Do not leave any questions, boxes, lines, etc. blank. Enter N/A if not applicable to you.
Action requested:
Date:
☐ New rendering affiliation
☐ Rendering disaffiliation
A. Affiliate Identification Information
1. Legal name of rendering provider as listed with IRS 2. Rendering national provider identifier (NPI)
3. Legal name of group provider as listed with IRS
4. Group national provider identifier (NPI)
Enter the enrolled service location(s) at which the rendering provider provides services for the group
provider listed in item 3. Attach additional pages if needed.
City
State ZIP code
Group NPI
5. Service location
(number, street, suite/room)
(9-digit)
6. Service location
City
State ZIP code
Group NPI
(9-digit)
(number, street, suite/room)
City
State ZIP code
Group NPI
7. Service location
(9-digit)
(number, street, suite/room)
City
State ZIP code
Group NPI
8. Service location
(9-digit)
(number, street, suite/room)
DHCS 4029 (Rev. 12/16)
Page 2 of 4
State of California
Department of Health Care Services
Health and Human Services Agency
B. Rendering Provider Signature
9. I declare under penalty of perjury under the laws of the State of California that the foregoing
information is true, accurate, and complete to the best of my knowledge and belief. I understand that
incorrect or inaccurate information may affect my eligibility to receive Medi-Cal reimbursement and
that I must report changes in the above information within 35 days to the Department of Health Care
Services, Provider Enrollment Division. I hereby further declare that I will abide by all Medi-Cal laws
and regulations and the Medi-Cal program policies and procedures as published in the Medi-Cal
Provider Manual. I understand that it is my responsibility to read the manual and its updates.
Printed legal name of rendering provider (last, first, middle)
Original signature of rendering provider
ATTACH A LEGIBLE COPY OF RENDERING PROVIDER’S DRIVER’S LICENSE OR STATE-
ISSUED ID
C. Group Provider Signature
10. I declare under penalty of perjury under the laws of the State of California that the foregoing
information is true, accurate, and complete to the best of my knowledge and belief. I understand that
incorrect or inaccurate information may affect my eligibility to receive Medi-Cal reimbursement and
that I must report changes in the above information within 35 days to the Department of Health Care
Services, Provider Enrollment Division. I hereby further declare that I will abide by all Medi-Cal laws
and regulations and the Medi-Cal program policies and procedures as published in the Medi-Cal
Provider Manual. I understand that it is my responsibility to read the manual and its updates. I am
authorized to sign this application pursuant to CCR, Title 22, Section 51000.30(a)(2)(B).
Printed legal name of person signing this affiliation with authority to legally bind the group listed.
Please see instructions under number 10 for who can sign. (last, first, middle)
Original signature of person signing this affiliation with authority to legally bind the group listed
11. Executed at:
___________________,
_____________, on
______________
(City)
(State)
(Date)
12. Notary Public:
Applicants and providers licensed pursuant to Division 2 (commencing with Section 500) of the
Business and Professions Code, the Osteopathic Initiative Act, or the Chiropractic Initiative Act
ARE NOT REQUIRED to have this form notarized. If notarization is required, the Certificate of
Acknowledgement signed by the Notary Public must be in the form specified in Section 1189 of
the Civil Code.
DHCS 4029 (Rev. 12/16)
Page 3 of 4
State of California
Department of Health Care Services
Health and Human Services Agency
D. Contact Person’s Information
13. Contact Person’s Name (last, first, middle)
Title/Position
E-mail address
Telephone number
Privacy Statement
(Civil Code Section 1798 et seq.)
All information requested on this form is mandatory. This information is required by the California
Department of Health Care Services and any other California State Departments that are delegated
responsibility to administer the Medi-Cal program, by the authority of the Welfare and Institutions
Code, Sections 14043 - 14043.75, the California Code of Regulations, Title 22, Sections 51000 –
51451 and the Code of Federal Regulations, Title 42, Part 455. The consequences of not supplying
the mandatory information requested are denial of enrollment as a Medi-Cal provider or denial of
continued enrollment as a provider and deactivation of all provider numbers used by the provider to
obtain reimbursement from the Medi-Cal program. Some or all of this information may also be
provided to the California State Controller’s Office, the California Department of Justice, the California
Department of Consumer Affairs, the California Department of Corporations, the California Franchise
Tax Board or other California state or local agencies as appropriate, fiscal intermediaries, managed
care plans, the Federal Bureau of Investigation, the Internal Revenue Service, Medicare Fiscal
Intermediaries, Centers for Medicare and Medicaid Services, Office of the Inspector General,
Medicaid, or as required or permitted by law. For more information or access to records containing
your personal information maintained by this agency, contact the Provider Enrollment Division at
(916) 323-1945.
DHCS 4029 (Rev. 12/16)
Page 4 of 4
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