Primary Care Clinic: Rural Health Clinic - Medi-Cal Certification (Non-Urbanized Area)
The following forms and information are required for rural health clinic (RHC) Medi-Cal certification for a licensed free-standing primary care clinic (PCC). 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.