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Click ‘Get Form’ to open the CHDP Laboratory Provider Application in the editor.
Begin by filling in your laboratory's legal name and provider number(s) as required. Ensure that this information matches your IRS records.
Provide your state laboratory license/registration number and, if applicable, your fictitious business name along with the necessary documentation.
Complete the business address section accurately, including street number, city, and ZIP code. Avoid using a P.O. Box.
Enter your primary business telephone number and fax number. Make sure these are active lines for communication.
Fill in the email address for electronic communications and specify the pay-to name for billing purposes.
Attach copies of required documents such as your CLIA certificate and FEIN verification before submitting the application.
Finally, ensure that both the Laboratory Director and Owner sign the application in blue ink, then submit it to the specified address.

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What documents are needed for a Medi-Cal application?

The AMCAS processing fee for the primary application is $175, which includes one medical school designation. Each additional school designation is $45. If you apply to 20 schools, the primary application alone costs $1,030.

Who is eligible 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 $1,800 for individuals or $2,433 for a couple, then you qualify for free, full scope Medi-Cal based on AD FPL rules.

What is the Medi-Cal application?

A Medical Application is a software program developed for smart mobile devices that utilizes behavioral intervention technologies to support a patient-centered approach in healthcare management.

What do Medi-Cal applications mean?

What information do I need? California Drivers License or Identification Card. Proof of California Residency. Immigration status. Birth Certificates, passports, naturalization certificates. Social Security and Medicare Card.