Ng Provider application includes the Medi-Cal Rendering Provider/Group/Affiliation/Disaffiliation Form (DHCS 4029, Rev. 12/16). DHCS 4029 is available at files.medi-cal.ca.gov/pubsdoco/forms.asp and must be submitted with the Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers (DHCS 6216, Rev. 5/17). Thank you for your recent inquiry regarding participation in the Medi-Cal program. Please complete the enclosed Medi-Cal provider enrollment.
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How to fill out the Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement For Physician/Allied/Dental online
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.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Review the instructions provided with the form meticulously to ensure clarity on required fields.
- Enter your National Provider Identifier (NPI). If you do not have one, include 'atypical' in the NPI field.
- Provide your legal name as registered with the Internal Revenue Service (IRS) and fill in your date of birth, gender, and residence address.
- Indicate your mailing address, ensuring it is where correspondence will be directed.
- Input your social security number, ensuring accuracy as this field is mandatory.
- Enter your driver's license or state-issued ID number and state of issuance, and attach a clear copy.
- Provide your professional license or certificate number, including effective and expiration dates, listing specialties if applicable.
- Fill in your business address, ensuring it is an actual location, not a P.O. Box.
- Include your primary business telephone number and contact person’s details, including name, phone number, and email address.
- Detail your proof of professional liability insurance, including the insurer’s name, policy number, and agent details, and attach a copy of your certificate.
- Complete the disclosure information thoroughly, answering all questions about convictions, program participation, and any relevant licenses.
- Sign the application where indicated, providing your printed name, and the city, state, and date of signing.
- Attach all required documents as per the instructions indicated in the application.
- 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!
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How to look up Medi-Cal number?
For general questions about Medi-Cal, members and medical providers can call the official helpline at 1-800-541-5555. Depending on the situation, you may also call Covered California at 1-800-300-1506 or your county's Medi-Cal office.
How many Medicaid providers are there in California?
Currently, a total of 24 plans contract with the Department of Health Care Services (DHCS) to provide Medi-Cal managed care services to beneficiaries.
What is Medi-Cal pave?
The Provider Application and Validation for Enrollment (PAVE) system is an interactive, web- based solution for the provider types who enroll with Medi-Cal through PED and manage their Medi-Cal accounts securely online.
Who do I contact for Medi-Cal provider enrollment?
If you are a provider type not yet eligible to submit an application via PAVE, you can request that a Medi-Cal enrollment application be mailed to you by calling the Medi-Cal Provider Service Center at (800) 541-5555(outside of California, please call (916) 636-1980).
How to check if a provider is enrolled in California Medicaid?
To verify enrollment with State Medi-Cal, you may search the Department of Health Care Services' (DHCS) database via one or both of the links below (Enter your National Provider Identifier (NPI) in the search field).
How do I check my Medicaid status in California?
Check your Medi-Cal Benefit Status By Smart Phone or Tablet. Visit BenefitsCal to: By Desktop Computer. To check your benefits with a desktop computer visit BenefitsCal.com. By Phone. To check the status of your benefits, visit BenefitsCal.com or call 888-472-4463. Request a replacement Benefit Issuance Card (BIC)
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