Medical Transportation Provider Application Package Instructions
You need to complete three separate Medi-Cal forms and attach a number of required documents as verification of information provided in the Medi-Cal forms. All questions and blanks on the forms must be completed. All forms require notarization. Also, legible and current copies of all required documents must be submitted in order for the application package to be considered complete. An incomplete application package will prolong your enrollment process because it will be returned to you for correction and/or completion. The Provider Enrollment staff can not make any changes to your documents.
Effective January 1, 2013, applicants requesting enrollment as a Medical Transportation Provider are subject to payment of an application fee upon submission of their application. The Medi-Cal Application Fee Requirements for Compliance with 42 Code of Federal Regulations Section 455.460 Regulatory Provider Bulletin offers specific information regarding this requirement. For current application fee information, please see the Current Application Fee document/page.
Please provide legible copies of current documents, as listed below.
1. National Plan and Provider Enumeration System (NPPES) confirmation for each National Provider Identifier (NPI) you list in the application package. Acceptable NPI documentation is one of the following: 1) NPI notification letter from the NPPES, 2) NPI notification e-mail from NPPES, or 3) NPI notification letter or e-mail from the Electronic File Interchange Organization (EFIO). Note: The name and business address of the applicant or provider on all forms must exactly match the name and practice location on the NPPES or EFIO notification. For information on how to apply for an NPI or update your information in NPPES, visit the Medi-Cal Web site at www.medi-cal.ca.gov, and click on the "NPI" link, or go to https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart.
2. Federal Employer Identification Number (FEIN) or Individual Taxpayer Identification Number (ITIN) verification, if a social security number is not used, by submitting a current Internal Revenue Service (IRS) generated document. The only acceptable documents include an IRS-generated Letter 147-C, IRS-generated Form 941 (Employer’s Quarterly Federal Tax Return), IRS-generated Form 8109-C (Deposit Coupon), or IRS-generated Form SS-4 (only the official Confirmation Notification of FEIN/ITIN assignment). Note: The legal name of the applicant or provider on all forms must exactly match the name on the IRS-generated document; and the applicant/provider must be an owner or officer of the entity listed on the IRS document. For further information, please contact the IRS at (800) 829-4933 or www.irs.gov.
3. Local Business License, Tax Certificate, and Permit for any city and/or county (geographic area) where you conduct your business activities. Note: The business name and business address of the applicant or provider on all forms must exactly match the business name and business address on all local licenses and permits. If a business license/permit is not required, please submit a written statement from your local city/county indicating that your business does not require any license/permit. For further information, please contact the City Clerk and/or visit the California State Association of Counties web site at www.csac.counties.org, click on the "California’s Counties" link, and select "County Web Sites."
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4. Recorded/stamped Fictitious Business Name Statement (FBNS), issued by the county where the principal place of business is located, if using a fictitious business name AND the business name is different from the legal name on your application. For example, in the case of a corporation, any name other than the corporation name on record with the Secretary of State requires a FBNS. Note: The business name of the applicant or provider on all forms, all local business licenses/permits, and the FBNS must exactly match. To determine the applicable county agency where fictitious business names are filed, please visit the California State Association of Counties Web site at www.csac.counties.org, click on the "California’s Counties" link, and select "County Web Sites."
5. Fully executed Partnership Agreement, if your business is a partnership. Processing delays may be avoided by indicating whether the entity is a General Partnership or Limited Partnership and also submitting the following:
a) For a General Partnership, a list of all partners with percent of ownership or control interest for each; or
b) For a Limited Partnership, information identifying the General Partner, and a list of all partners with percent of ownership or control interest for each.
To verify or change the name and/or status of your partnership or for further information, please visit the Secretary of State California Business Portal Web page at www.sos.ca.gov/business/business.htm, and click on the "California Business Search" link or other appropriate link.
6. If your business is a corporation, processing delays may be avoided by attaching a copy of the filed Articles of Incorporation from the Secretary of State, and a list of directors’ and officers’ names and titles, with percent of ownership and control interest for each.
To verify or change the name and/or status of your corporation or for further information, please visit the Secretary of State California Business Portal Web page at www.sos.ca.gov/business/business.htm, and click on the "California Business Search" link or other appropriate link.
7. Certificate of Commercial Liability Insurance (business, general, or comprehensive liability, or office premises insurance) in an amount of not less than $100,000 per claim and a minimum annual aggregate of $300,000. Acceptable verification is either evidence of being self-insured, or a certificate of insurance or declaration sheet issued by the insurance company that contains the name of the insurance company, the name and business address of the insured, effective dates, and limits of coverage. Note: The name and business address, including suite number if applicable, of the applicant or provider on all forms must exactly match the insured’s name and address on the certificate of insurance or declaration sheet.
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8. Certificate of Workers’ Compensation Insurance is required by California law, if your business has one or more employees. Acceptable verification is either evidence of being self-insured, or a certificate of insurance or declaration sheet issued by the insurance company that contains the name of the insurance company, the name of the insured, and effective dates. If no Workers’ Compensation insurance is required, an explanation must be provided. Note: The name of the applicant or provider must exactly match the insured’s name on the certificate of insurance.
9. Signed Lease Agreement, if business premises are not owned by the applicant or provider. Note: The name and business address of the applicant or provider must exactly match the lessee’s name and address on the lease agreement.
10. Successor Liability with Joint and Several Liability Agreement (DHCS 6217), if applicable. For further information on using successor liability, visit the Medi-Cal Web site at www.medi-cal.ca.gov, and click on the "Provider Enrollment" link, then "Statutes, Regulations and Provider Bulletins, " and then select the Provider Bulletins entitled "Important Reminder: Providers Selling or Purchasing a Business" and "Requirements and Procedures for Successor Liability."
11. Ambulance Information, if applicable
Copy of current CHP 301 Certificate(s)
Copy of Local EMS Certificate(s)
Copy of CHP Ambulance License(s)
Ambulance Driver(s) Information
Copy of Ambulance Driver Certificate(s)
Copy of Ambulance Driver Driver’s License(s)
12. Aircraft Information, if applicable
Copy of FAA Certificate(s)
Copy of EMS Certificate(s)
Statement on company letterhead of where aircraft is/are hangared
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Copy of FAA Pilot’s License(s)
Copy of Driver’s License(s)
13. Litter and/or Wheelchair Van Information
Copy of DMV Commercial Vehicle Registration
Copy of Proof of Commercial Vehicle Insurance
Copy of Brake Certificate
Copy of Lamp Certificate
Copy of Special Vehicle Permit (if applicable)
Litter and/or Wheelchair Van Driver Information
Copy of DMV Driving Record Printout
Copy of Certificate for First Aid
Copy of Certificate for CPR
Copy of Standard pre-employment drug test (listing drugs tested for)
Copy of Alcohol Test Lab Results
Copy of California Driver’s license
Copy of DMV DL-51 Form ( 4 pages) signed by a Physician
Copy of Special Driver Permit ( if applicable)
14. Copy of Driver’s License or state-issued identification card (issued within the 50 United States or the District of Columbia) of the provider, or person signing the forms who has the authority to legally bind the applicant or provider. The signature must be that of the provider, unless the provider is a corporation, governmental entity or non-profit organization. If the provider is one of these three entity types and the forms are going to be signed by a person other than the provider, please submit documentation that identifies the signing person’s authority to legally bind the corporation or non-profit organization or to represent the governmental entity.
You may need to submit additional documents depending upon answers to certain questions on the Medi-Cal Disclosure Statement (DHCS 6207). The document requirements are subject to change depending upon future changes in enrollment regulations and/or state law.
PROCEED TO THE 3 APPLICATION FORMS NEEDED
1.Medi-Cal Provider Application Form (DHCS 6206)
2.Medi-Cal Disclosure Statement Form (DHCS 6207)
3. Medi-Cal Provider Agreement Form (DHCS 6208)