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State of California—Health and Human Services Agency
California Department of Public Health

Chronic Dialysis Clinic: End-stage Renal Disease - Medi-​Cal Certification
Applicant Checklist

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

HS 328

​Notice – Effective Date of Provider Agreement

  • If applying for both Medi-Cal & Medicare certification, only need one copy of this form.

DHCS 6207

​Medi-Cal Disclosure Agreement

  • Only complete section V.

DHCS 9098

​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.

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