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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

Form HS 269 - Application for Med-Cal Certification as a Primary Care Clinic Provider​

 


Please complete all items and if applicable, provide all requested supplemental documents. Do not leave any items blank. If a question does not apply, respond with “Not Applicable” or “N.A.”. The following table provides further details for the section/item # that require special instruction(s).

​Section / Item #

1. ​Clinic name (dba)

  • Medi-Cal provider number(s):
    Note: USE National Provider Identifier (NPI) No. in lieu of Medi-Cal provider number.

​2. If this is an intermittent clinic, what is the name (dba) and address of the parent clinic:

  • Medi-Cal provider number(s):
    Note: USE National Provider Identifier (NPI) No. in lieu of Medi-Cal provider number.

​3. Legal name of entity (corporation) owning clinic

  • Medi-Cal provider number(s):
    Note: USE National Provider Identifier (NPI) No. in lieu of Medi-Cal provider number.

Note:

 



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