Get Application For Medi-cal Certification As A Primary Care Clinic Provider. Hs 269 - Cdph Ca

Filling out the Application For Medi-Cal Certification As A Primary Care Clinic Provider (HS 269) is a crucial step for clinics seeking certification. This guide provides step-by-step instructions to help you accurately complete the application online, ensuring you meet all necessary requirements.

Follow the steps to successfully complete your application.

1. Click the 'Get Form' button to access the application. This action will enable you to open the form in your online editor for filling it out.
2. Begin by specifying the type of application: select 'Initial application,' 'Change of ownership application,' or 'Update' based on your situation.
3. Enter the clinic name (doing business as) in the designated field. Next, provide the street address, including the number and street name, and any applicable P.O. Box details.
4. Fill in the clinic's telephone and fax numbers, including area codes. Then, provide the city, state, ZIP code, and the Federal Employer Identification Number (EIN). If available, include your current Medi-Cal provider number.
5. If your clinic operates intermittently, enter the details of the parent clinic, including its name, street address, P.O. Box, telephone number, fax number, city, state, EIN, and Medi-Cal provider numbers.
6. List the legal name of the entity that owns the clinic. Provide the clinic's street address, including any P.O. Box details, along with the telephone and fax numbers, city, state, EIN, and Medi-Cal provider numbers for the entity.
7. Complete questions 4 through 8 regarding the clinic listed in question 1. For question 4, describe the specific types of services, advice, and treatments the clinic will offer.
8. For question 5, indicate the source of funding and income for operating the clinic.
9. In question 6, check the boxes for each day of the week that the clinic is open for business.
10. In question 7, specify the number of hours the clinic is open, matching the days you checked in the previous step.
11. In question 8, enter the number of hours that patients are seen for appointments corresponding to the days checked.
12. Lastly, complete the declaration statement, print your name, sign the document, include your title, and date it.
13. Once you have filled in all required fields and confirmed the accuracy of your information, you can save the changes, download, print, or share the completed form as needed.

Complete your Medi-Cal certification application online today to ensure your clinic meets all necessary requirements.