Most Popular Links
- Find a Medi-Cal Dentist
- Provider Seminars
- Provider Bulletins
- Provider Handbook
- Dental Resources
- Stop Fraud and Abuse
- California Children's Services
- County Offices to Apply for Medi-Cal
Denti-Cal Application Forms
A complete application package includes:
- The application
- 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.
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.
- Online-fillable forms will display helpful tips when you hover your mouse pointer over a fill-in field or checkbox.
- Sample Applications Here you will find examples of completed application forms.
- Denti-Cal Enrollment Outreach Providers are offered one-on-one assistance with their enrollment application packages.
Enrollment Application Package
The application package is 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, Includes Helpful Hover Tips)
- Medi-Cal Provider Application (DHCS 5300)
- Medi-Cal Supplemental Changes (DHCS 6209, revised 10/16)
Use this form to report changes to previously submitted information.
- Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers (DHCS 6216, revised 2/15)
Required for new rendering providers not currently enrolled in program.
- Medi-Cal Change of Location Form for Individual Physician or Individual Dentist Practices Relocating within the same County (DHCS 9096, revised 1/11)
- Successor Liability with Joint and Several Liability Agreement (DHCS 6217, revised 2/08)
- Electronic Funds Transfer (EFT) Enrollment Form
Billing Providers can receive Medi-Cal dental payments directly to their business checking account by completing the forms in this package.
- IRS Form W9
- Crossover Only Provider Form (MC0804)
- Medi-Cal Dental Provider and Billing Intermediary Application/Agreement
- Orthodontia Provider Certification Form
If applicable, include with the enrollment application.