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Get Medi-cal Rendering Provider Application/disclosure Statement/agreement For Physician/allied/dental

Ng Provider application includes the Medi-Cal Rendering Provider/Group/Affiliation/Disaffiliation Form (DHCS 4029, Rev. 12/16). DHCS 4029 is available at files.medi-cal.ca.gov/pubsdoco/forms.asp and must be submitted with the Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers (DHCS 6216, Rev. 5/17). Thank you for your recent inquiry regarding participation in the Medi-Cal program. Please complete the enclosed Medi-Cal provider enrollment.

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