Hospice Facility: Medi-Cal Certification
A "certified" HOSPICE has to be separately licensed as a hospice. The following forms and information are required for Medi-Cal certification.
If you answered "YES" on Item A.7.of the HS 200 form (Do You Wish to Apply for the Medi-Cal Program?) and your hospice wants to provide services to Medi-Cal beneficiaries (under Title 19), submit the following forms with your "initial" application package.
Once the hospice has become certified for Medicare, they may provide services to Medi-Cal beneficiaries, if requested. The hospice is required to be licensed prior to seeking certification status.
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.
Hospice Request for Certification in the Medicare Program
- If applying for both Medi-Cal and Medicare certification, only need one copy of this form.
- If this hospice is being certified for Medi-Cal "only," the only reason this form is being requested is for the listing of the types of services.
- Complete this form as indicated.