Online Application PDF Form
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Facility Information - Medicare Certification Documents (Only applicable for Medicare Certification)
CMS 1561 – Health Insurance Benefit Agreement (PDF)
HS 328 – Notice-Effective Date of Provider Agreement (PDF)
HHS 690 – Assurance of Compliance (PDF) (Submit a verification from the Office of Civil Rights displaying submission of this form)
Facility Information - Medi-Cal Certification Documents (Only applicable for Medi-Cal Certification)
DHCS 9098 – Medi-Cal Provider Agreement (PDF, 2.9MB)
DHCS 6207 – Medi-Cal Disclosure Statement (PDF) (Only submit Section V – Subcontractor Information and Significant Business Transactions)
HS 328 – Notice-Effective Date of Provider Agreement (PDF)
One of the following Internal Revenue Service tax documents:
Form 941 – Employer’s Quarterly Federal Tax Return
Form 8109-C – FTD Address Change
Letter 147-C – EIN Verification Letter
Form SS-4 – Application for Employer Identification Number
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.