Form DHCS9096 "Medi-Cal Change of Location Form for Individual Physician or Individual Dentist Practices Relocating Within the Same County" - California

What Is Form DHCS9096?

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 August 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 DHCS9096 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 DHCS9096 "Medi-Cal Change of Location Form for Individual Physician or Individual Dentist Practices Relocating Within the Same County" - 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 Physician Provider:
Thank you for your participation in the Medi-Cal program. This Medi-Cal Change of Location Form For
Individual Physician Practices Relocating Within the Same County form (DHCS 9096, Rev. 8/17), is solely
for use by doctors of medicine and osteopathic physicians who are changing business locations within the
same county and who meet the definition of an “individual physician practice”, pursuant to Welfare and
Institutions Code (W&I Code), Section 14043.26(b). “Individual physician practice” is defined in W&I
Code, Section 14043.1(l)(2) as “a physician and surgeon licensed by the Medical Board of California or
the Osteopathic Medical Board of California enrolled or enrolling in Medi-Cal as an individual provider who
is sole proprietor of his or her practice or is a corporation owned solely by the individual physician and the
only physician practitioner is the owner. An individual physician practice may include non-physician
medical practitioners employed and supervised by the physician.”
Please note that by submitting this form, you attest that you meet the definition of an individual physician
practice, that you are changing locations within the same county, and that the most recent application
information you submitted to the Department of Health Care Services (DHCS), with the exception of the
current change in location being reported, remains true, accurate, and complete to the best of your
knowledge and belief. If you do not meet all of these criteria, then you must submit a complete application
package consisting of the most current versions of the Medi-Cal Physician Application/Agreement form
(DHCS 6210, Rev. 5/17) and the Medi-Cal Disclosure Statement form (DHCS 6207, Rev. 2/17).
Once you have completed the enclosed form, please return it to:
Department of Health Care Services
Provider Enrollment Division
MS 4704
P.O. Box 997412
Sacramento, CA 95899-7412
Please carefully read all the instructions included in the DHCS 9096 form and complete each item
requested. You will receive notification of receipt of your application package within 15 days of DHCS
receiving it. Incomplete forms will be returned.
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 Physician Provider:
Thank you for your participation in the Medi-Cal program. This Medi-Cal Change of Location Form For
Individual Physician Practices Relocating Within the Same County form (DHCS 9096, Rev. 8/17), is solely
for use by doctors of medicine and osteopathic physicians who are changing business locations within the
same county and who meet the definition of an “individual physician practice”, pursuant to Welfare and
Institutions Code (W&I Code), Section 14043.26(b). “Individual physician practice” is defined in W&I
Code, Section 14043.1(l)(2) as “a physician and surgeon licensed by the Medical Board of California or
the Osteopathic Medical Board of California enrolled or enrolling in Medi-Cal as an individual provider who
is sole proprietor of his or her practice or is a corporation owned solely by the individual physician and the
only physician practitioner is the owner. An individual physician practice may include non-physician
medical practitioners employed and supervised by the physician.”
Please note that by submitting this form, you attest that you meet the definition of an individual physician
practice, that you are changing locations within the same county, and that the most recent application
information you submitted to the Department of Health Care Services (DHCS), with the exception of the
current change in location being reported, remains true, accurate, and complete to the best of your
knowledge and belief. If you do not meet all of these criteria, then you must submit a complete application
package consisting of the most current versions of the Medi-Cal Physician Application/Agreement form
(DHCS 6210, Rev. 5/17) and the Medi-Cal Disclosure Statement form (DHCS 6207, Rev. 2/17).
Once you have completed the enclosed form, please return it to:
Department of Health Care Services
Provider Enrollment Division
MS 4704
P.O. Box 997412
Sacramento, CA 95899-7412
Please carefully read all the instructions included in the DHCS 9096 form and complete each item
requested. You will receive notification of receipt of your application package within 15 days of DHCS
receiving it. Incomplete forms will be returned.
Provider Enrollment Division
MS 4704
P.O. Box 997412, Sacramento, CA 95899-7412
Internet Address: www.dhcs.ca.gov/provgovpart/Pages/PED.aspx
PLEASE NOTE: Applicants and providers are required to submit their National Provider Identifier (NPI)
with each Medi-Cal provider application package and to attach a copy of the Centers for Medicare &
Medicaid Services (CMS)/National Plan and Provider Enumeration System (NPPES) confirmation for the
NPI listed in the application package.
It is your responsibility to report to DHCS any changes in information previously submitted within 35 days
from the date of the change. Most changes may be reported on the most current version of the Medi-Cal
Supplemental Changes form (DHCS 6209, Rev. 10/16). However, you must complete a new, full
application package when reporting a change of ownership of 50 percent or more 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 form (DHCS 6217, Rev. 5/17).
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 above 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 form (DHCS 6153, Rev. 3/17), available on the Medi-Cal Website at
www.medi-cal.ca.gov and click on the “Provider Enrollment” link. If you have any questions about
obtaining an electronic billing submitter number, call the Telephone Service Center (TSC) at
1-800-541-5555 and select the option for Computer Media Claims (CMCs).
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
CHANGE OF LOCATION FORM FOR INDIVIDUAL PHYSICIAN OR INDIVIDUAL DENTIST
PRACTICES RELOCATING WITHIN THE SAME COUNTY
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 “Medi-Cal Change of Location Form for Individual Physician or Individual Dentist Practices Relocating
Within the Same County” (Change of Location Form) is solely for use by dentists or physicians who are
changing business locations within the same county and meet the definition of an “individual dentist practice”
as defined by Welfare and Institutions (W&I) Code Section 14043.1(l)(1), or of an “individual physician
practice” as defined by W&I Code Section 14043.1(l)(2). This Change of Location Form may be submitted
in lieu of a complete application package, pursuant to W&I Code Section 14043.26(b).
W&I Code Section 14043.1(l)(1) “‘Individual dentist practice’ means a dentist licensed by the Dental
Board of California enrolled or enrolling in Medi-Cal as an individual provider who is a sole
proprietor of his or her practice or is a corporation owned solely by the individual dentist and the
only dentist practitioner is the owner. An individual dentist practice may include nondentist allied
dental health professionals employed and supervised by the dentist.”
W&I Code Section 14043.1(l)(2) “‘Individual physician practice’ means a physician and surgeon
licensed by the Medical Board of California or the Osteopathic Medical Board of California enrolled
or enrolling in Medi-Cal as an individual provider who is sole proprietor of his or her practice or is a
corporation owned solely by the individual physician and the only physician practitioner is the
owner. An individual physician practice may include nonphysician medical practitioners employed
and supervised by the physician.”
By submitting this form, you, the applicant are attesting that you meet the definition of an individual dentist
or individual physician practice, are changing locations within the same county and attesting that your most
recent application, including the last Medi-Cal Disclosure Statement, submitted to the Department of Health
Care Services, with the exception of the change in location being reported now, remains true, accurate, and
complete to the best of your knowledge and belief. If you do not meet all of these criteria and you are a
dentist, you must submit a complete application package consisting of a Medi-Cal Provider Application
(DHCS 6204), a Medi-Cal Disclosure Statement (DHCS 6207), and a Medi-Cal Provider Agreement (DHCS
6208). If you do not meet all of these criteria and you are a physician, you must submit a complete application
package consisting of a Medi-Cal Physician Application/Agreement (DHCS 6210) and a Medi-Cal
Disclosure Statement (DHCS 6207).
Omission of any information on this form, including the original signature of the applicant/provider,
or the failure to provide all required documentation may result in the denial of this form 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.
DHCS 9096 (Rev. 8/17)
Page 1 of 5
State of California
Department of Health Care Services
Health and Human Services Agency
Instructions
1. “Legal name”—enter the name listed with the Internal Revenue Service (IRS).
2. “Provider number”—enter the National Provider Identifier (NPI) used at the new business address
indicated in item 5.
3. “Business name”—enter the business name if different than the legal name indicated in item 1.
4. “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.
5. “New business address”—enter the new 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.
6. “Pay-to address”—enter the address at which the 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.
7. “Mailing address”—enter the location at which the provider wishes to receive general Medi-Cal or
Denti-Cal correspondence. General Medi-Cal or Denti-Cal correspondence includes bulletin updates
and Provider Manual updates. The mailing 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.
8. “Local business license/permit numbers”—enter any local business license or permit numbers for
any city and/or county where you conduct your business and attach copies to the application. If this
does not apply to you, enter N/A and provide an explanation.
9. Enter the Clinical Laboratory Improvement Amendment (CLIA) certificate number—attach a legible
copy of the CLIA certificate. The name and address on the certificate must match the name and
address as entered in items 1 and 5.
10. Enter the State Laboratory License/Registration Number—attach a legible copy of the
license/registration. The name and address on the certificate must match the name and address as
entered in items 1 and 5.
11. “Previous
business address”—enter the previous business location.
12. Enter the requested information. Attach to this application a legible copy(ies) of applicant’s or
provider’s current Certificate of Insurance for Liability Insurance that covers premises and operation
for this address.
13. Print name of the dentist or physician 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
Title 22, California Code of Regulations, Section 51000.30(a)(2)(B) to determine whether you have
the authority to sign this form.
14. Enter the dental or medical license number of the applicant/provider and attach a legible copy of the
license.
15. 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.
DHCS 9096 (Rev. 8/17)
Page 2 of 5
State of California
Department of Health Care Services
Health and Human Services Agency
 Remember to attach a legible copy of the following, if applicable:
National Provider Identifier verification (CMS/NPPES confirmation)
Local business license(s) or permit(s)
CLIA Certificate
State Laboratory License/Registration
Driver’s license or state-issued identification card
Certificate(s) of Insurance for Comprehensive Liability Insurance
Dental or Medical license
DHCS 9096 (Rev. 8/17)
Page 3 of 5
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