Dental Office Letterhead
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Sincerely, Denti-Cal California Medi-Cal Dental Program Provider Enrollment Enclosures State of California—Health and Human Services Agency Department of Health Care Services INS T R UC T IONS F OR C OMP L E T ION OF T HE ME DI-C AL C HANG E OF L OC AT ION F OR M F OR INDIV IDUAL P HY S IC IAN OR INDIV IDUAL DE NT IS T PRACTICES RELOCATING WITHIN THE SAME COUNTY DO NOT USE staples on this form or on any attachments.. An individual physician practice may include nonphysician medical practitioners employed and supervised by the physician.” By submitting this form, you, the applicant are attesting that you meet the definition of an individual dentist or individual physician practice, are changing locations within the same county and attesting that your most recent application, including the last Medi-Cal Disclosure Statement, submitted to the Department of Health Care Services, with the exception of the change in location being reported now, remains true, accurate, and complete to the best of your knowledge and belief.. Remember to attach a legible copy of the following, if applicable: National Provider Identifier verification (CMS/NPPES confirmation) Local business license(s) or permit(s) CLIA Certificate State Laboratory License/Registration Driver’s license or state-issued identification card Certificate(s) of Insurance for Comprehensive Liability Insurance Dental or Medical license DHCS 9096 (rev 01/11) Page 2 of 3 State of California – Health and Human Services Agency Department of Health Care Services ME DI-C AL C HANG E OF L OC AT ION F OR M F OR INDIV IDUAL PHYSICIAN OR INDIVIDUAL DENTIST PRACTICES RELOCATING WITHIN THE SAME COUNTY FOR STATE USE ONLY Important: Read all instructions before completing the form..
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