PEAP Applications/Forms

• MEDI-CAL Provider Agreement
• MEDI-CAL Disclosure Statement (DHCS 6207)
• MEDI-CAL Durable Medical Equipment Provider Application (DHCS 6201)
• MEDI-CAL Pharmacy Provider Application (DHCS 6205)
• MEDI-CAL Physician Application/Agreement (DHCS 6210)
• MEDI-CAL Provider Application (DHCS 6204)
• MEDI-CAL Clinical Medical Laboratory (DHCS 6204)
• MEDI-CAL Provider Group Applications (DHCS 6203)
• MEDI-CAL Orthotics and Prosthetics Provider Application (DHCS 6202)
• MEDI-CAL NonPhysician Medical Practioner and Licensed Midwife Application (DHCS 6248)
• MEDICAL Supplemental Changes (DHCS 6209)
• MEDICAL Medical Transportation Provider Application (DHCS 6206)
• MEDI-CAL Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers (DHCS 6216)
• Successor Liability with Joint and Several Liability Agreement (DHCS 6217)
• National Provider Identifier Registration Form (DHCS 6218)
• MEDI-CAL Provider Number Verification Form