Denti-Cal Application Forms

A complete application package includes:

• The application
• Provider agreement
• Disclosure statement
• All required attachments as stated on the forms

Please read and follow all instructions on each form carefully. Incomplete application packages will be returned and will delay your enrollment in the Medi-Cal program. Only current forms will be accepted as part of a complete application package.

Based on the services you provide, you can select below an Enrollment Application Package that will include the appropriate enrollment forms and instructions combined as one zip file, or you can select the Enrollment Application Forms individually.

Note: All providers must be enrolled in the Denti-Cal program and receive a confirmation letter prior to rendering dental services to Medi-Cal beneficiaries. After enrollment, group providers must continue to confirm the enrollment of all rendering providers prior to allowing the rendering providers to issue services to Medi-Cal beneficiaries.

Enrollment Application Assistance

This section contains helpful information to correctly fill out and submit enrollment forms.

• Online-fillable forms will display helpful tips when you hover your mouse pointer over a fill-in field or checkbox.
• Tips for Success – Describes ways to submit an application package correctly and avoid the chance of a returned application.
• Helpful Hints Guide for the Medi-Cal Disclosure Statement – This Guide will give you helpful advice on filling out the Medi-Cal Disclosure Statement.
• Helpful Hints for Completing Denti-Cal Enrollment Application Forms – This Guide will give you helpful advice on filling out the Denti-Cal Enrollment Application Forms.
• Sample Applications – Here you will find examples of completed application forms.
• Denti-Cal Enrollment Outreach – Providers are offered one-on-one assistance with their enrollment application packages.

Enrollment Application Packages

Application packages are in zip format and will require a file compression program such as WinZip to open. The individual forms are in Portable Document Format (PDF) and some are online-fillable. You will need to use the latest version of Adobe Reader to open and use the forms. WinZip and Adobe Reader can be downloaded for free from the Medi-Cal Web Tool Box. You can also visit Adobe.com/Reader to obtain the current version of Adobe Reader.

Important note: when using Adobe Reader, the fillable forms can not be saved with data that you type in. Print the forms in order to retain the information you have entered. By using the fillable features of the forms, the forms are more legible and the hover tips will assist with many questions you may have. Whether filling out the forms using a computer or pen, you must sign, and mail them to the Denti-Cal Program. Forms cannot be returned via e-mail to the Denti-Cal Program.

• Medi-Cal Provider Group Application Package
• Medi-Cal Provider Application Package

Enrollment Application Forms

If you need specific enrollment application forms. (Key: Online-Fillable, Includes Helpful Hover Tips)

• Medi-Cal Provider Group Application (DHCS 6203, revised 2/08)
• Medi-Cal Provider Application (DHCS 6204, revised 2/08)
  Required for all provider types for whom a specific application is not listed on this page.
• Medi-Cal Disclosure Statement (DHCS 6207, revised 2/15)
  Required for all provider applicants unless the Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers (DHCS 6216) is used.
• Medi-Cal Provider Agreement (DHCS 6208, revised 11/11)
  Required for all provider applicants unless the Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers (DHCS 6216) is used.
• Medi-Cal Supplemental Changes (DHCS 6209, revised 12/14)
  Use this form to report changes to previously submitted information.
• Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers (DHCS 6216, revised 2/15)
  Required for new rendering providers not currently enrolled in program.
• Medi-Cal Change of Location Form for Individual Physician or Individual Dentist Practices Relocating within the same County (DHCS 9096, revised 1/11)
• Successor Liability with Joint and Several Liability Agreement (DHCS 6217, revised 2/08)
• Electronic Funds Transfer (EFT) Enrollment Form
  Billing Providers can receive Medi-Cal dental payments directly to their business checking account by completing the forms in this package.
• IRS Form W9
• Crossover Only Provider Form (MC0804)
• Medi-Cal Dental Provider and Billing Intermediary Application/Agreement
  
• Orthodontia Provider Certification Form
  If applicable, include with the enrollment application.