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MEDI-CAL RENDERING PROVIDER APPLICATION DISCLOSURE

MEDI-CAL RENDERING PROVIDER APPLICATION DISCLOSURE 2025

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4.7 out of 5

34 votes

The document provides detailed instructions for completing the Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for physicians, allied health, and dental providers in California. It outlines the necessary steps, required information, and documentation needed for enrollment or continued participation in the Medi-Cal program. Key points include prohibitions on using staples or correction fluid, mandatory disclosures regarding criminal history and professional conduct, and requirements for proof of professional liability insurance. The document emphasizes the importance of accuracy and completeness to avoid application denial.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your legal name as listed with the IRS in the designated field. Ensure accuracy to avoid processing delays.
Fill in your date of birth and gender. These fields are essential for identification purposes.
Provide your residence address, ensuring all details are correct, including city, state, and ZIP code.
Complete the mailing address section if different from your residence. This is where correspondence will be sent.
Enter your Social Security number in the mandatory field. Refer to the Privacy Statement for guidance on data protection.
Input your driver’s license or state-issued ID number along with a copy attached for verification.
Continue filling out sections regarding professional licenses and insurance details, attaching necessary documentation as specified.
Review all disclosure information carefully, checking applicable boxes and providing dates where required.
Finally, sign and date the application at the bottom, ensuring all required attachments are included before submission.

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Versions	Form popularity	Fillable & printable
2017	4.1 Satisfied (60 Votes)
2015	4.7 Satisfied (34 Votes)
2005	4 Satisfied (31 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Can I go to any doctor if I have Medi-Cal?

Once you are enrolled in a Medi-Cal health plan, you need to choose a primary care doctor who works with your Medi-Cal health plan. You can ask your current doctor if they work with a Medi-Cal health plan in your county.

What are the new rules for Medi-Cal in California?

Basic Information. Beginning January 1, 2024, a new law in California will allow adults ages 26 through 49 to qualify for full-scope Medi-Cal, regardless of immigration status. All other Medi-Cal eligibility rules, including income limits, will still apply.

What is the 3 month rule for Medi-Cal?

Retroactive Medi-Cal covers unpaid medical expenses from the three months prior to the month you apply for Medi-Cal. If you have unpaid bills from the three previous months, enter that information during the application process. If you qualify for Medi-Cal, you will also be evaluated for retroactive coverage.

How do I remove OHC from Medi-Cal?

If the OHC appears in error, then you, the beneficiary, or their representative can request a correction by contacting DHCS at (800) 541-5555 or submitting a removal form at .

What will disqualify you from Medi-Cal?

The Medi-Cal program determines eligibility for benefits on a means tested basis. If a Medi-Cal applicants property/assets are over the Medi-Cal property limit, the applicant will not be eligible for Medi-Cal unless they lower their property/assets ing to the program rules.

How much can I make a month and still qualify for Medi-Cal?

The number you get is the amount of monthly income that is counted for the AD FPL program. If it is less than $1,732 for individuals or $2,351 for a couple, then you qualify for free, full scope Medi-Cal based on AD FPL rules.

Can I have money in the bank and still get Medi-Cal?

In 2024, renewal forms will no longer ask for asset information. That means you can keep your savings and assets and still keep your Medi-Cal coverage. It is important to open and review any mail received from your county about your Medi-Cal coverage.

How do I change my Medi-Cal provider in California?

If you are in a Medi-Cal health plan and want to choose another health plan for any reason, you may leave the health plan and join a different health plan. You can call Health Care Options (HCO), toll free, at 1-800-430-4263 (TTY 1-800-430-7077), 8 a.m. to 6 p.m. PT, Monday through Friday, except holidays.

MEDI-CAL RENDERING PROVIDER APPLICATION DISCLOSURE 2025

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