Form DHCS6248 "Medi-Cal Non-physician Medical Practitioner and Licensed Midwife Application" - California

What Is Form DHCS6248?

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 May 1, 2017;
  • 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 DHCS6248 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 DHCS6248 "Medi-Cal Non-physician Medical Practitioner and Licensed Midwife Application" - California

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State of California—Health and Human Services Agency
Department of Health Care Services
EDMUND G. BROWN JR.
JENNIFER KENT
DIRECTOR
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 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 DHCS any modifications to information previously submitted within
35 days from the date of the change. Most changes may be reported on the a Medi-Cal Supplemental
Changes form (DHCS 6209, Rev. 10/16). 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).
Enrollment forms are available at www.medi-cal.ca.gov or by contacting the Telephone Service Center
(TSC) at (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.
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
EDMUND G. BROWN JR.
JENNIFER KENT
DIRECTOR
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 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 DHCS any modifications to information previously submitted within
35 days from the date of the change. Most changes may be reported on the a Medi-Cal Supplemental
Changes form (DHCS 6209, Rev. 10/16). 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).
Enrollment forms are available at www.medi-cal.ca.gov or by contacting the Telephone Service Center
(TSC) at (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.
Provider Enrollment Division
MS 4704
P.O. Box 997412, Sacramento, CA 95899-7412
Internet Address: www.dhcs.ca.gov/provgovpart/Pages/PED.aspx
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 e-mail 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 Website at www.medi-cal.ca.gov, under “References”, “Forms”, then “Billing.”
Provider Enrollment Division
Enclosures
(Rev. 8/17)
State of California
Department of Health Care Services
Health and Human Services Agency
INSTRUCTIONS FOR COMPLETION OF THE
MEDI-CAL NON-PHYSICIAN MEDICAL PRACTITIONER AND LICENSED MIDWIFE APPLICATION
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 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. Additional information can be
found on the Medi-Cal Web site (www.medi-cal.ca.gov) by clicking the “Provider Enrollment” link.
Omission of any information or documentation on this form or failure to sign any of these
documents may result in any of the denial actions identified 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.
Enrollment action requested (check all that apply). Enter the date you are completing the application.
“Add new”
—the Non-Physician Medical Practitioner or Licensed Midwife is not currently enrolled in the
Medi-Cal program under the listed Employing Provider.
“Delete” —you no longer wish to be enrolled as a practitioner under the listed Employing Provider.
“Change” —you need to change information previously submitted to the Department.
“Continued Enrollment” —you are currently enrolled in the Medi-Cal program and would like to continue
participation. (Do not check this box unless you have been requested by the Department to apply for
continued enrollment in the Medi-Cal program pursuant to CCR, Title 22, Section 51000.55)
Note: If you are enrolling as an individual provider do not submit this application form. Please submit a
MEDI-CAL PROVIDER APPLICATION (DHCS 6204), a MEDI-CAL DISCLOSURE STATEMENT (DHCS
6207) and a MEDI-CAL PROVIDER AGREEMENT (DHCS 6208).
A. Non-Physician Medical Practitioner or Licensed Midwife Information
1. “Legal name”
—enter the name listed with the Internal Revenue Service (IRS).
2. Enter the driver’s license number or state-issued identification card number and state of issuance.
Attach a legible copy.
3. Enter the Non-Physician Medical Practitioner or Licensed Midwife’s National Provider Identifier.
Attach a copy of the CMS/NPPES confirmation.
DHCS 6248 (Rev. 5/17)
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State of California
Department of Health Care Services
Health and Human Services Agency
4. Enter
the nine-digit social security number or Taxpayer Identification Number (TIN) and attach a
legible copy of the IRS Form 941, Form 8109-C, Letter 147-C, or Form SS-4 (Confirmation
Notification). See Privacy Statement on page 10.
5.
Enter the date of birth of the individual listed in number 1.
6. Check the gender of the individual listed in number 1.
7. Enter the practitioner’s or midwife’s license or certification number and attach a legible copy to the
application.
8. Enter the date the practitioner was first employed by the employing provider identified on this
application form. Attach verification of employment.
9. Enter the effective date of the license/certification number.
10. Enter the expiration date of the license/certification number.
11. Enter the maximum number of hours per week the practitioner works at the business address
identified in number 17.
12. Enter the number of hours per week the practitioner is supervised at this business address by the
supervising physician identified in number 23.
13. Nurse Practitioners only —enter the duration of the nurse practitioner training program.
14. Nurse Practitioners only —enter the name of the school at which the nurse practitioner training
program was completed.
15. List taxonomy codes associated with your NPI. Attach additional sheets if necessary.
B. Employing Provider Information
16. “Legal name” —enter the name of the individual or the business name of the entity listed with the
IRS. Indicate if this is a business entity.
17. Enter the employing provider’s business address including the street address, city, state, and ZIP
code at which the practitioner will render services.
18. Enter the medical license number of the employing provider, if applicable. Attach a legible copy of
the license.
19. Enter the employing provider’s National Provider Identifier for the address identified in number 17.
20. Check the box for the type of facility identified as the business address identified in number 17.
21. Check the box for the primary type of service delivered at the business address identified in number
17.
22. “Business telephone number” —enter the primary business telephone number used at the business
address identified in number 17. A beeper number, cell phone, answering service, pager, facsimile
machine, biller or billing service, or answering machine shall not be used as the business telephone
number.
C. Supervising Physician Information
23. “Legal name” —enter the supervising physician’s name listed with the IRS.
24. Enter the supervising physician’s medical license number(s). Attach a legible copy.
25. Enter the supervising physician’s National Provider Identifier.
DHCS 6248 (Rev. 5/17)
Page 2 of 10
State of California
Department of Health Care Services
Health and Human Services Agency
26. Enter the supervising physician’s driver’s license number or state-issued identification number and
state of issuance. Attach a legible copy.
27. Enter the telephone number at which the supervising physician can be reached.
28. Enter the date of birth of the individual listed in number 23.
29. Check the gender of the individual listed in number 23.
30. Enter the type of practice or specialty of the supervising physician.
31. List the name(s) and practitioner type of any other Non-Physician Medical Practitioners or Licensed
Midwife currently being supervised at this and other locations by the supervising physician
identified in number 23. List the maximum number of hours the practitioner works each week.
NOTE: The Business and Professions Code (Articles 2 and 2.5 of Chapter 6 and Chapter 7.7) limits
the number of practitioners a single primary care physician is allowed to supervise. It is the
responsibility of the supervising physician to ensure that the number of practitioners being
supervised does not exceed that limit. One supervising physician is limited to supervising a
maximum of four practitioners at one time in any combination as long as the limit for each
practitioner type established in the Business and Professions Code is not exceeded. Additional
limits are defined in Welfare and Institutions Code, Section 14043.47, that states in relevant
part that a physician doing business as a sole proprietorship, partnership, or professional
corporation under Part 4 (commencing with Section 13400) of Division 3 of the Corporations
Code or a physician provider in a group may not be enrolled at more than three business
addresses unless there is a ratio of at least one physician providing supervision for every three
locations.
D. Additional Information
32. If the Non-Physician Medical Practitioner or Licensed Midwife works for no other Medi-Cal
providers, check the “None” box. Otherwise, enter the name, provider number, business address,
and maximum hours worked per week for each additional Medi-Cal provider for whom the Non-
Physician Medical Practitioner or Licensed Midwife works. The Non-Physician Medical Practitioner
or Licensed Midwife must be enrolled at each location.
E. Information about person signing the application for Employing Provider
33. “Legal Name and Title” —enter the signing person’s name listed with the IRS and their title at the
Employing Provider.
34. Enter the signing person’s driver’s license number or state-issued identification number and state of
issuance. Attach a legible copy.
35. Enter the signing person’s social security number. (This field is optional—see Privacy Statement on
page 10)
36. Enter the date of birth of the individual listed in number 33.
37. Check the gender of the individual listed in number 33.
F. Insurance Information
38. 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 e-mail address of the
insurance agent. You must also attach a copy of your certificate of insurance to the application.
DHCS 6248 (Rev. 5/17)
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