Form DHCS6204 "Medi-Cal Provider Application" - California

What Is Form DHCS6204?

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 February 1, 2017;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHCS6204 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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State of California—Health and Human Services Agency
Department of Health Care Services
JENNIFER KENT
EDMUND G. BROWN JR.
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, California, 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
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.
Applicants and providers may be required to submit an application fee or proof of payment to or
enrollment with Medicare or other state Medicaid programs. Effective January 1, 2013, Department of
Health Care Services (DHCS) requires certain applicants and providers to submit an application fee when
requesting an enrollment action. The application fee collected is used to offset the cost of conducting the
required screening as specified in Title 42 Code of Federal Regulation 455 Subpart E. Please reference the
Medi-Cal Regulatory Provider Bulletin, “Medi-Cal Application Fee Requirements for Compliance with 42
Code of Federal Regulations Section 455.460,” for further information.
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 most current version of 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).
Provider Enrollment Division
MS 4704
P.O. Box 997412, Sacramento, CA 95899-7412
Phone: (916) 323-1945
Internet Address: www.dhcs.ca.gov/provgovpart/Pages/PED.aspx
State of California—Health and Human Services Agency
Department of Health Care Services
JENNIFER KENT
EDMUND G. BROWN JR.
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, California, 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
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.
Applicants and providers may be required to submit an application fee or proof of payment to or
enrollment with Medicare or other state Medicaid programs. Effective January 1, 2013, Department of
Health Care Services (DHCS) requires certain applicants and providers to submit an application fee when
requesting an enrollment action. The application fee collected is used to offset the cost of conducting the
required screening as specified in Title 42 Code of Federal Regulation 455 Subpart E. Please reference the
Medi-Cal Regulatory Provider Bulletin, “Medi-Cal Application Fee Requirements for Compliance with 42
Code of Federal Regulations Section 455.460,” for further information.
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 most current version of 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).
Provider Enrollment Division
MS 4704
P.O. Box 997412, Sacramento, CA 95899-7412
Phone: (916) 323-1945
Internet Address: www.dhcs.ca.gov/provgovpart/Pages/PED.aspx
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. 02/08).
Enrollment forms are available at www.medi-cal.ca.gov or by contacting the Telephone Service Center 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.
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
most current version of the Medi-Cal Telecommunications Provider and Biller Application/Agreement,
(DHCS 6153, Rev. 11/13), available on the Medi-Cal Website at www.medi-cal.ca.gov, under “Provider
Resources”, “Forms”, then “Billing.”
Provider Enrollment Division
Enclosures
(Rev. 2/17)
State of California
Department of Health Care Services
Health and Human Services Agency
INSTRUCTIONS FOR COMPLETION OF THE
MEDI-CAL PROVIDER 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.
You must submit an application fee and/or fee waiver request unless you are exempt from paying
the fee. DHCS will only accept a cashier’s check made payable to the State of California,
Department of Health Care Services, in the amount required for the calendar year in which DHCS
receives your application. Information regarding the current fee is available on the DHCS Web
site at www.dhcs.ca.gov. Failure to submit a cashier’s check when required may result in denial
of your application.
Enrollment action requested - check all that apply. Enter the date you are completing the application.
“New provider” —check if the applicant is not currently enrolled in the Medi-Cal program as a provider
with an active provider number. Include the NPI for the business address indicated in item 4.
“Change of business address”—check if the applicant is currently enrolled in the Medi-Cal program and is
requesting to relocate to a new business address and vacate the old location. Indicate the business
address applicant is moving from.
“Additional business address”—check if the applicant is currently enrolled in the Medi-Cal program and is
requesting enrollment for an additional business location.
“New Taxpayer ID Number”—check if a new Taxpayer Identification Number (TIN) has been issued by
the IRS.
DHCS 6204 (Rev. 2/17)
Page 1 of 10
State of California
Department of Health Care Services
Health and Human Services Agency
“Change of ownership”—check if there is a change of ownership as defined in CCR, Title 22, Section
51000.6. Indicate the effective date in the space provided.
“Cumulative change of 50 percent or more in person(s) with ownership or control interest”—check if there
is a cumulative change of 50 percent or more in the person(s) with ownership or control interest, as
defined in CCR, Title 22, Section 51000.15, since the information provided in the last complete application
package that was approved for enrollment. Indicate the effective date in the space provided.
“Sale or transfer of assets (50 percent or more)”—check if 50 percent or more of the assets owned by the
corporation, at the location for which a provider number has been issued, are sold or transferred. Indicate
the effective date in the space provided.
“Continued Enrollment”—check if the applicant is currently enrolled as a Medi-Cal provider and has been
requested by the Department to apply for continued enrollment in the Medi-Cal program. Do not check
this box unless you have received notification from the Department, pursuant to CCR, Title 22, Section
51000.55. List current provider number(s) in the space provided.
Check the box labeled “I intend to use my current . . . .” if you intend to use your current provider number
to bill for services delivered at this location while this application request is pending. This action places
the provider on provisional provider status, pursuant to CCR, Title 22, Section 51000.51.
Medi-Cal Application Fee – check all that apply.
Check the box labeled “I am requesting enrollment as an individual …” if you are requesting enrollment
as an individual non-physician practitioner. These providers are exempt from paying the application fee
pursuant to W&I Code Section 14043.25(d) and the provider bulletin, “Medi-Cal Application Fee
Requirements for Compliance with 42 Code of Federal Regulations Section 455.460,” January 2013.
Check the box labeled “I am currently enrolled in the Medicare program…” if you are currently enrolled in
the Medicare program at the business address indicated on page 8, item 4 of the application, and under
the legal name listed on page 8, item 1 of the application. Provider locations are exempt from paying the
fee if currently enrolled in Medicare pursuant to W&I Code Section 14043.25(d) and the provider bulletin,
“Medi-Cal Application Fee Requirements for Compliance with 42 Code of Federal Regulations Section
455.460,” January 2013. Verification is required: provide an official notice from the enrolling agency that
specifies the applicant’s/provider’s legal name and physical business address as identified on this
application.
Check the box labeled “I am currently enrolled in another State’s…” if you are currently enrolled in another
State’s Medicaid or Children’s Health Insurance Program (CHIP) at the business address indicated on
page 8, item 4 of the application, and under the legal name listed on page 8, item 1 of the application.
Provider locations are exempt from paying the fee if currently enrolled in another State’s Medicaid or CHIP
pursuant to W&I Code Section 14043.25(d) and the provider bulletin, “Medi-Cal Application Fee
Requirements for Compliance with 42 Code of Federal Regulations Section 455.460,” January 2013.
Verification is required: provide an official notice from the enrolling agency that specifies the
applicant’s/provider’s legal name and physical business address as identified on this application.
Check the box labeled “I have paid the application fee…” if you have paid the application fee to a Medicare
contractor or another State’s Medicaid or CHIP for the enrollment of the business address indicated on
page 8, item 4 of the application, and under the legal name listed on page 8, item 1 of the application.
Providers are exempt from paying the fee if they have already paid the fee to a Medicare contractor or
another State’s Medicaid or CHIP for the same business address pursuant to W&I Code Section
14043.25(d) and the provider bulletin, “Medi-Cal Application Fee Requirements for Compliance with 42
Code of Federal Regulations Section 455.460,” January 2013. Verification is required: provide official
DHCS 6204 (Rev. 2/17)
Page 2 of 10
State of California
Department of Health Care Services
Health and Human Services Agency
proof of payment that specifies the applicant’s/provider’s legal name and physical business address as
identified on this application.
Check the box labeled “I have included an application fee…” if you included with the application either an
application fee cashier’s check, fee waiver request, or both. Providers that do not meet the exemptions
specified in the above boxes are required to pay the fee pursuant to W&I Code Section 14043.25(d) and
the provider bulletin, “Medi-Cal Application Fee Requirements for Compliance with 42 Code of Federal
Regulations Section 455.460,” January 2013. DHCS can only accept a cashier’s check as payment
of the application fee – made payable to the State of California, Department of Health Care
Services.
“Type of entity”—check the box which applies to your business structure. Your corporate status will be
verified using the corporate number and state in which incorporated. If a partnership, you must attach a
legible copy of the partnership agreement. If you check “other,” list the type of legal entity.
1. “Legal name” is the name listed with the Internal Revenue Service (IRS).
2. “Business name” is the name of the applicant or provider if different from that listed in number 1. If
this is a Fictitious Business Name, provide the Fictitious Business Name Statement/Permit number
and effective date. Attach a legible copy of the recorded/stamped Fictitious Business Name
Statement/Permit to the application. Physician provider groups are to submit a legible copy of the
Fictitious Business Name Permit issued by the Medical Board of California.
3. “Business telephone number” is the primary business telephone number used at the business
address. A beeper number, cell phone, answering service, pager, facsimile machine, biller or billing
service phone, or answering machine shall not be used as the primary business telephone.
4. “Business address” is the actual business location including the street name and number, room or
suite number or letter, city, county, state, and nine-digit ZIP code. A post office or commercial box
is not acceptable.
a. Check whether the business address is a licensed health facility as defined in Sections 1250,
1250.2 and 1250.3 of the Health and Safety Code. Check whether services will be rendered at
only the business address indicated. If not, you must submit a separate application for each
business address unless you qualify for an exception pursuant to W&I Code Section
14043.15(b)(2). See the ‘Facility-Based Provider’ bulletin on the Medi-Cal Web site
(www.medi-cal.ca.gov) for the requirements to qualify for that exception.
5. “Pay-to address” is the address at which the applicant or provider wishes to receive payment. The
pay-to address should include, as applicable, the post office box number, street number and name,
room or suite number or letter, city, state, and nine-digit ZIP code.
6. “Mailing address” is the address at which the applicant or provider wishes to receive general Medi-
Cal correspondence. General Medi-Cal correspondence includes bulletin updates and Provider
Manual updates.
7. “Previous business address” is the address where the applicant or provider was previously enrolled.
If the applicant or provider is not submitting an application for a change of location, enter N/A.
8. Enter the license/certificate number, or other approval to provide health care, of the applicant or
provider. Attach a legible copy of the license, certificate, or approval. Enter the effective date and
the expiration date of the license/certificate number, or other approval.
DHCS 6204 (Rev. 2/17)
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