DRUG MEDI-CAL PROVIDER AGREEMENTDrug Medi-Cal Provider Agreement • May 25th, 2020 • California
Date Legal name of applicant or provider Business name (if different than legal name) Provider number (NPI) Business telephone number( ) Business address (number, street) City State ZIP code (nine-digit) Mailing address (number, street, P.O. Box number) City State ZIP code (nine-digit) Previous business address (number, street) City State ZIP code (nine-digit)
DRUG MEDI-CAL PROVIDER AGREEMENTDrug Medi-Cal Provider Agreement • May 5th, 2020 • California
Legal name of applicant or provider Business name (if different than legal name) Provider number (NPI) Business Telephone Number Business address (number, street) City State ZIP code (9-digit) Mailing address (number, street, P.O. Box number) City State ZIP code (9-digit) Previous business address (number, street) City State ZIP code (9-digit) Taxpayer Identification Number (TIN)*
Drug Medi-Cal Provider Agreement Now AvailableDrug Medi-Cal Provider Agreement • May 26th, 2020
The new Drug Medi-Cal Provider Agreement (DHCS 6009) is now available in the Application Forms by Form Name and Number section of the Provider Enrollment page of the Medi-Cal website. Additional information about the agreement, including requirements for completing and submitting the agreement, is available in the article Medi-Cal Requirement for the Drug Medi-Cal Provider Agreement.
