Personal Care Agency (PCA) Application Requirements
- 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
- Home Care Organization (HCO) 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.
