Skilled Nuring Facility or Intermediate Care Facility: Medi-Cal Certification
The forms and information are required for Medi-Cal certification. 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 Statement
NOTE: Only complete section V.
Medi-Cal Provider Agreement
- Do not leave questions blank. Enter N/A or "same" if not applicable.
- The "mailing address" must be the same as reported on the HS 200 form, page 3, Item 4.
- Signature page must contain original signatures.
- Submit the "Acknowledgement" page from the Notary Public, if applicable.