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Governor Brown

Are you on the Denti-Cal Provider Referral List?

Denti-Cal Application Forms

A complete application package includes:

  • The application
  • Provider agreement
  • Disclosure statement
  • All required attachments as stated on the forms

Please read and follow all instructions on each form carefully. Incomplete application packages will be returned and will delay your enrollment in the Medi-Cal program. Only current forms will be accepted as part of a complete application package.

Based on the services you provide, you can select below an Enrollment Application Package that will include the appropriate enrollment forms and instructions combined as one zip file, or you can select the Enrollment Application Forms individually.

Note: All providers must be enrolled in the Denti-Cal program and receive a confirmation letter prior to rendering dental services to Medi-Cal beneficiaries. After enrollment, group providers must continue to confirm the enrollment of all rendering providers prior to allowing the rendering providers to issue services to Medi-Cal beneficiaries.

Enrollment Application Assistance

This section contains helpful information to correctly fill out and submit enrollment forms.

Enrollment Application Packages

Application packages are in zip format and will require a file compression program such as WinZip to open. The individual forms are in Portable Document Format (PDF) and some are online-fillable. You will need to use the latest version of Adobe Reader to open and use the forms. WinZip and Adobe Reader can be downloaded for free from the Medi-Cal Web Tool Box. You can also visit Adobe.com/Reader to obtain the current version of Adobe Reader.

Important note: when using Adobe Reader, the fillable forms can not be saved with data that you type in. Print the forms in order to retain the information you have entered. By using the fillable features of the forms, the forms are more legible and the hover tips will assist with many questions you may have. Whether filling out the forms using a computer or pen, you must sign, and mail them to the Denti-Cal Program. Forms cannot be returned via e-mail to the Denti-Cal Program.

Enrollment Application Forms

If you need specific enrollment application forms. (Key: Online-Fillable Online-Fillable, Includes Hover Tips Includes Helpful Hover Tips)

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