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:
- currently licensed as a PCC and applying for certification, or
- applying for initial licensure as a PCC and certification, or
- applying for change of ownership, or
- exempt from licensure and applying for certification only.
|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.
|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
|HHS 690 (PDF)|
Assurance of Compliance
Note: Submit a copy of the confirmation page.
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.
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.
|HS 269 (PDF)|
|Application for Medi-Cal Certification as a Primary Care Clinic Provider||X|||||||
|HS 309 (PDF)|
Note: The HS 309 is required if you are only applying for certification and not for licensure.
HS 328 (PDF)||Notice – Effective Date of Provider Agreement||X||X||X||X|
|HS 610 (PDF)||Medically Underserved or Health Professional Shortage Areas||||X||X||X|