Get Mc 803

Filling out the Mc 803 form is a crucial step for providers seeking to register with Medi-Cal. This guide offers clear, step-by-step instructions to help users navigate the online process effectively and accurately.

Follow the steps to complete your Mc 803 form online

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the corporate name in section 1(c). If applicable, provide additional details in section 1(d).
3. In section 2, fill out the legal name as it appears on records from the IRS or Social Security Administration in 2(a) and the facility name in 2(b).
4. Complete the facility address in section 3, including street number, city, county, state, and zip code.
5. Provide the telephone number associated with the facility in section 4.
6. Enter the federal employer’s tax ID number or Social Security number linked to the name in section 2(a) in section 5.
7. In section 6(a), check the box that corresponds to the type of organization—state, county, city government, nonprofit, for-profit, or corporation.
8. In section 6(b), indicate the type of ownership by checking the appropriate box.
9. List the facility owner(s) and their professional license numbers in section 7. If further space is needed, attach an additional sheet.
10. Indicate any additional facilities or practices associated with the owners in section 8.
11. List any previous Medi-Cal provider numbers related to the owners in section 9.
12. Address the question in section 10 regarding whether the facility is a teaching facility, marking ‘Yes’ or ‘No.’
13. In sections 11-14, type or print the applicant’s name, title, and date, and ensure you provide a signature where indicated.
14. Finally, review all entries for accuracy. Save changes, download the completed form, print it for records, or share it as needed.

Complete your Mc 803 form online today to ensure your registration with Medi-Cal.