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Update Your LEA Contact Information

You may change your LEA’s contact information and/or addresses by submitting to DHCS the Annual Report (AR), which is due every year on November 30th from all participating LEAs. Page 1 of the AR, Medi-Cal Provider Enrollment Information Sheet, will allow you to notate any changes to your LEA’s information. If your LEA’s contact information changes after your last submission of the AR, but before the submission period for the following year, please submit an updated page 1 only. You do not need to resubmit the entire AR.

Please email your submissions to: LEA.AnnualReport@dhcs.ca.gov  

Important Note 

If your LEA is changing its mailing/payment address, you must also submit Form 6209 to the Provider Enrollment Division (PED). You may send Form 6209 to the address listed on the cover page of the form. Please note: Form 6209 must be notarized before it is mailed to PED.

Last modified date: 3/23/2021 9:09 AM