Primary Care Clinic: Rural Health Clinic - Medicare Certification (Non-Urbanized Area)
The following forms and information are required for rural health clinic (RHC) Medicare 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.
|Medicare General Enrollment Health Care Provider/Supplier Application|
- This application is from the Federal Department of Health and Human Services.
- The completed application should be mailed directly to the appropriate fiscal intermediary.
|Health Insurance Benefit Agreement |
Submit two (2) signed copies with "original" signatures.
|OMB No. 0990-0243||Civil Rights Information Request for Medicare Certification |
- Complete and "sign" form (original signature).
- Submit copy of all items required on the form.
- All 9 items need to be "identified" and accounted for; however, if less than 15 employees, Item #6 does not apply.
- DO will not review these items since they are to be approved by OCR.
Assurance of Compliance
- Submit 1 copy. This HHS 690 form is the first document required to be submitted on the above OMB No. 0990-0243 form.