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LEA Provider Enrollment

 An LEA must complete the following enrollment requests to become an LEA provider in the Medi-Cal program.  All enrollment requests can be accessed through the following link:

  1. Provider Participation Agreement
  2. Certification of State Matching Funds for LEA Services (Attachment 1)
  3. Certification of State Matching Funds for LEA Services For Retroactive Claiming (Attachment 1A)
  4. Statement of Commitment to Reinvest (Attachment 2)

 

LEA providers that want to be reimbursed for targeted case management services must complete the Targeted Case Management Labor Survey (PDF).  More information about targeted case management services may be found in the LEA Provider Manual (loc ed serv targ) (Word).


 

 LEA Enrollment Flowchart (Ppt)