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 Contact Us

Phone: (916) 552-8632

For application status requests, please include the following in your email:

  • Name of Facility or Agency
  • License or Facility/Agency # (if applicable)
  • Address
  • Facility or Provider Type
  • Date Documentation Sent
  • Contact Number​​​​​

​​​​​General Acute Care Hospitals and Acute Psychiatric Hospitals

Change of Facility Mailing Address

Required Documents

Online Application PDF Form
  • Embedded and generated by online system
Facility Information - Medi-Cal Certification Documents (Only applicable for Medi-Cal Certification)
  • DHCS 9098​ (PDF) form​ - Medi-Cal Provider Agreement​​
Helpful Tips
  • Specify if the request is for the main or distinct part (D/P) facility or service.
  • Submit a Change of Mailing Address (CHMA) application(s) for the following:
    • ​​Facility mailing address changes.
    • ​​​​Medi-Cal pay-to-address changes. 
  • ​Submit a Change of Certification (CHOC) application to add/remove Medi-Cal and/or Medicare certification.
  • ​Submit a Change of National Provider Identifier (CNPI) for NPI changes.
  • ​Submit a Change of Name (CHON) to update the legal or business name.

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