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EDMUND G. BROWN JR.
Governor

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



Primary Care Clinic

Applying for Medi-Cal and/or Medicare certification​

 


The following documents are required if you are applying for Medi‑Cal and/or Medicare certification and you are:

  1. currently licensed as a PCC and applying for certification, or 
  2. applying for initial licensure as a PCC and certification, or 
  3. applying for change of ownership, or 
  4. exempt from licensure and applying for certification only.
Form # Form Name​ Medi-Cal​ Medi-Cal only RHC​ Medicare only RHC​ Currently licensed Medicare RHC​
CMS 29 (PDF)​Request to Establish Eligibility​X​X​X
CMS 855A (PDF)​Medicare General Enrollment Health Care Provider/Supplier Application​X​X
CMS 1561A (PDF)​Health Insurance Benefits Agreement​X​X
DHCS 6207 Section V (PDF)

​Medi-Cal Disclosure Statement

Note: Only complete section V.

​X
DHCS 9098 (PDF)

​Medi-Cal Provider Agreement

Note: The “Mailing address” must be the same as reported on the HS 200 form, Page 3, Section C.3, C.4

​X​X
HHS 690 (PDF)

​Assurance of Compliance

Note: Submit a copy of the confirmation page.

​X​X
HS 200 (PDF)

​Licensure and Certification Application

Note: The HS 200 is still required if you are only applying for certification. If you are applying for both licensure and certification, the HS 200 is already required and another HS 200 is not required.

​X​X
HS 215A (PDF)

​Applicant Individual Information

Note: The HS 215A is still required if you are only applying for certification. If you are applying for both licensure and certification, the HS 215A is already required and another HS 215A is not required.

​X
HS 269 (PDF)
Instr Cklst
​Application for Medi-Cal Certification as a Primary Care Clinic Provider​X
HS 309 (PDF)

​Administrative Organization

Note: The HS 309 is required if you are only applying for certification and not for licensure.

X​X​
HS 328 (PDF)​Notice – Effective Date of Provider Agreement​X​X​X​X
HS 610 (PDF)​Medically Underserved or Health Professional Shortage Areas​XX​X​

 



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