July 30, 2013 Dear Medi-Cal Provider: NOTIFICATION OF REVIEW FOR CONTINUED CERTIFICATION IN THE DRUG MEDI-CAL PROGRAM---COMPLETE APPLICATION PACKAGE IS REQUIRED WITHIN 30 DAYS This letter provides written notice that the Department of Health Care Services, (DHCS) is certifying providers for continued participation in the Drug Medi-Cal program. If you want to apply for continued certification as a provider in the Drug Medi-Cal program, you must submit the Drug Medi-Cal Application for Substance Abuse Clinics (DHCS 6001, revised 07/13), the Medi-Cal Disclosure Statement (DHCS 6207, revised 11/11 ), and complete the Facility Staffing Data Form for each individual that provides direct treatment services. The forms (enclosed) must be returned within 30 days of the date of this notice. Failure to do so will result in termination and decertification as a Drug Medi-Cal provider. This written notification is being mailed to the business address on file with DHCS. Please complete the enclosed Drug Medi-Cal Application for Substance Abuse Clinics, Disclosure Statement and the Facility Staffing Data Form and return within 30 days of this notice to the address below. FAX will not be accepted. Department of Health Care Services Attention: Re-Enrollment Section MS 4704 P.O. Box 997412 Sacramento, CA 95899-7412 Failure to complete and return the enclosed attachments within 30 days of the date of this notice will be treated as a decision not to continue as a Drug Medi-Cal provider. Should decertifiction occur, DHCS will inform you of the termination of the application and decertification as a Drug Medi-Cal provider. If you have any questions or require additional information, please contact the Re-Enrollment Unit message center, ai(916) 319-8412. Provider Enrollment Division Enclosure Provider Enrollment Division MS 4704 P 0. Box 997412, Sacramento, CA 95899-7412 Internet Address: htto:l/www.DHCS.ca.aov