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P.O. Box 15609
Sacramento, CA 95852-0609
(800) 423-0507
(916) 853-7373
Dear Provider:
Thank you for your participation in the Medi-Cal Dental Program (Denti-Cal). This Medi-Cal
Change of Location Form For Individual Physician or Individual Dentist Practices Relocating
Within the Same County (DHCS 9096, rev 01/11) is solely for use by dentists who are changing
business locations within the same county and who meet the definition of an “individual dentist
practice”, pursuant to Welfare and Institutions (W & I Code), Section 14043.26(b).
“Individual dentist practice” is defined in W & I Code Section 14043.1(I)(1) as “a dentist licensed
by the Dental Board of California enrolled or enrolling in Medi-Cal as an individual provider who
is sole proprietor of his or her practice or is a corporation owned solely by the individual dentist
and the only dentist practitioner is the owner. An individual dentist may include non-dentist allied
dental health professionals employed and supervised by the dentist.”
Please note that by submitting this form, you attest that you meet the definition of an individual
dentist practice, that you are changing locations within the same county, and that the most
recent application information you submitted to the Denti-Cal Program, with the exception of the
current change of location being reported, remains true, accurate, and complete to the best of
your knowledge and belief. If you do not meet all of these criteria, then you must submit a
complete application package consisting of a Medi-Cal Provider Agreement (DHCS 6208) and
the Medi-Cal Disclosure Statement (DHCS 6207).
Once you have completed the enclosed form, please return it to:
Medi-Cal Dental Program (Denti-Cal)
Provider Enrollment
P.O. Box 15609
Sacramento, California, 95852-0609
Please carefully read all the instructions included in the Medi-Cal Change of Location Form for
Individual Physician or Individual Dentist Practices Relocating Within the Same County
(DHCS 9096, rev 01/11) and complete each item requested. You will receive notification of
receipt of your application package within 15 days of Provider Enrollment receiving it.
Incomplete forms will be returned.
Applicants and providers are required to submit their National Provider Identifier (NPI) with each
Medi-Cal provider application package. A copy of the CMS/National Plan and Provider
Enumeration System (NPPES) confirmation document for each NPI listed in the application
package must also be included. Current Medi-Cal providers are required to submit both the NPI
and any Medi-Cal provider numbers issued previously on any application forms submitted to the
Denti-Cal Program.