Provider Forms

Listed below are all available provider forms for the Denti-Cal program. These forms can be downloaded, printed and mailed.

Provider Enrollment

Denti-Cal Provider Application Package
  • Denti-Cal Provider Application (DHCS 5300)
  • Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers (DHCS 6216)
  • Successor Liability with Joint and Several Liability Agreement (DHCS 6217)
  • IRS Form W9
  • Electronic Funds Transfer (EFT) Enrollment Form
  • Medi-Cal Dental Patient Referral Service
  • EDI Enrollment Packet
  • EDI How-to Guide
  • Denti-Cal Glossary of Abbreviations
  • Orthodontia Provider Certification Form
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IRS Form W9
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General

EDI

Cover Sheet
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