Individual Nurse Provider (INP) Application Requirements
- Medi-Cal Provider Application, DHCS 6204 (notarization not required)
- Medi-Cal Disclosure Statement, DHCS 6207 (notarization not required)
- Medi-Cal Provider Agreement, DHCS 6208 (notarization not required)
- Proof of National Provider Identifier (NPI): NPPES NPI Registry Confirmation
- Department of Consumer Affairs (DCA) License Printout
- Valid State-Issued ID or Driver’s License
- Valid Basic Life Support (BLS) Certification
- Professional Liability (Malpractice) Insurance Coverage
Resume. Describe training and experience providing nursing care to patients.
For LVN applicants only: Provide the name of the RN who will be providing ongoing supervision, along with the RN’s license number.
For RN applicants only: Include a breakdown of hours worked for each position listed from the last five years, e.g., 40 hours per week x 52 weeks per year = total number of hours worked per year.
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. 