Get Medi-cal Rendering Provider Application/disclosure Statement/agreement For Physician/allied/dental

Filling out the Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement is a crucial step for professionals seeking to enroll in California's Medi-Cal program. This guide provides a step-by-step approach to help users complete the application online efficiently and accurately.

Follow the steps to successfully complete your application online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Review the instructions provided with the form meticulously to ensure clarity on required fields.
3. Enter your National Provider Identifier (NPI). If you do not have one, include 'atypical' in the NPI field.
4. Provide your legal name as registered with the Internal Revenue Service (IRS) and fill in your date of birth, gender, and residence address.
5. Indicate your mailing address, ensuring it is where correspondence will be directed.
6. Input your social security number, ensuring accuracy as this field is mandatory.
7. Enter your driver's license or state-issued ID number and state of issuance, and attach a clear copy.
8. Provide your professional license or certificate number, including effective and expiration dates, listing specialties if applicable.
9. Fill in your business address, ensuring it is an actual location, not a P.O. Box.
10. Include your primary business telephone number and contact person’s details, including name, phone number, and email address.
11. Detail your proof of professional liability insurance, including the insurer’s name, policy number, and agent details, and attach a copy of your certificate.
12. Complete the disclosure information thoroughly, answering all questions about convictions, program participation, and any relevant licenses.
13. Sign the application where indicated, providing your printed name, and the city, state, and date of signing.
14. Attach all required documents as per the instructions indicated in the application.
15. After reviewing all your entries for accuracy, save changes, and download or print the completed form.

Start filling out your Medi-Cal Rendering Provider Application online today to ensure your participation in the program!