Online Application PDF Form
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Facility Information - Medi-Cal Certification Documents (Only applicable for Medi-Cal Certification)
DHCS 9098 – Medi-Cal Provider Agreement (PDF, 2.9MB)
Helpful Tips
Specify if the request is for the main or distinct part (D/P) facility or service.
Submit a Change of Mailing Address (CHMA) application(s) for the following:
Facility mailing address changes.
Medi-Cal pay-to-address changes.
Submit a Change of Certification (CHOC) application to add/remove Medi-Cal and/or Medicare certification.
Submit a Change of National Provider Identifier (CNPI) for NPI changes.
Submit a Change of Name (CHON) to update the legal or business name.