Chronic Dialysis Clinic: End-stage Renal Disease - Medi-Cal Certification
The following forms and information are required for Medi-Cal certification. Medi-Cal certification only applies to End-Stage Renal Disease facilities.
Note: All forms listed are in PDF format.
|Form #||Description||Check List|
Notice – Effective Date of Provider Agreement
- If applying for both Medi-Cal & Medicare certification, only need one copy of this form.
Medi-Cal Disclosure Agreement
Medi-Cal Provider Agreement
- Do not leave any questions blank. Enter N/A or "same" if not applicable.
- The "mailing address" must be the same as reported on the HS 200 form.
- Signature page must be notarized.
- Submit the "Acknowledgement" page from the Notary Public, if applicable.