Qhov Chaw Kho Mob Nyob Rau Cov Neeg Laus (RCFE) lossis Adult Residential Facility (ARF) Daim Ntawv Thov
- Application Fee: Cashier’s Check in the amount of $730.00 made payable to the Department of Health Care Services
- Medi-Cal Provider Application, DHCS 6204 (must be notarized)
- Medi-Cal Disclosure Statement, DHCS 6207 (must be notarized)
- Medi-Cal Provider Agreement, DHCS 6208 (must be notarized)
- Kev lag luam email cuam tshuam rau RCFE/ARF
- Proof of National Provider Identifier (NPI): NPPES NPI Registry Confirmation
- Pov thawj ntawm Tsoom Fwv Teb Chaws Tus Neeg Them Se Tus Naj Npawb (TIN): IRS Tsab Ntawv SS-4, IRS Daim Ntawv 941, Daim Ntawv 8109-C, lossis Tsab Ntawv 147-C
- Daim ntawv tso cai ua lag luam hauv nroog lossis tsab ntawv zam
- Daim ntawv tso cai muab los ntawm Department of Social Services
- Lub Xeev Muab ID lossis Daim Ntawv Tso Cai Tsav Tsheb (nrog rau cov ntawv luam rau txhua tus neeg muaj npe nyob rau hauv daim ntawv Medi-Cal)
- Ua Lag Luam Raws Li (DBA) lossis Cov Lus Qhia Lub Npe Ua Lag Luam (yuav tsum tau tsuas yog tias kev lag luam ua haujlwm raws li lub npe txawv dua li lub npe lag luam uas twb muaj lawm)
- General Liability Insurance
- Nyiaj Pov Hwm Kev Ua Haujlwm
- Surety Bond lossis Exemption Letter
- Secretary of State Confirmation
- Cov khoom ntawm Incorporation los yog Cov Khoom ntawm Lub Koom Haum
Xa daim ntawv thov ua tiav pob rau:
Department of Health Care Services
Integrated Systems of Care Division
Chaw Muab Npe Rau Npe
1501 Capitol Avenue, MS 4502
PO ib 997437
Sacramento, CA 95899-7437
THOV NCO NTSOOV: Xa pob khoom mus rau qhov chaw muab kev tso npe nkag
TSIS TXAUS SIAB TXOJ CAI TXOJ CAI NTAWM TUS TSWV TSEV KAWM NTAWV
If you have questions regarding the application requirements, call (916) 552-9105, option 5, then option 2. Email inquiries can be sent to WaiveProEnroll@dhcs.ca.gov.