• 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)
• Business email associated to the RCFE/ARF
• Proof of National Provider Identifier (NPI): NPPES NPI Registry Confirmation
• Proof of Federal Taxpayer Identification Number (TIN): IRS Letter SS-4, IRS Form 941, Form 8109-C, or Letter 147-C
• City Business License or Exemption Letter
• Facility license issued by the Department of Social Services
• Valid State Issued ID or Driver’s License (include copies for all individuals listed on the Medi-Cal forms)
• Doing Business As (DBA) or Fictitious Business Name Statement (required only if business is operating under a name different than the existing corporate name)
• General Liability Insurance
• Workers’ Compensation Insurance
• Surety Bond or Exemption Letter
• Secretary of State Confirmation
• Articles of Incorporation or Articles of Organization

Submit complete application package to:

Department of Health Care Services

Integrated Systems of Care Division

Provider Enrollment Unit

1501 Capitol Avenue, MS 4502

P.O. Box 997437

Sacramento, CA 95899-7437

PLEASE NOTE: SEND PACKAGE TO THE PROVIDER ENROLLMENT UNIT 

DO NOT SEND ANY DOCUMENTS TO THE PROVIDER ENROLLMENT DIVISION

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.