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DENTI-CAL PROVIDER APPLICATION

Important: all FOR STATE USE ONLY

Do not leave any questions, boxes, lines, etc. blank. Enter N/A if not applicable to you. Visit the Denti-Cal Website for helpful tools to aid in completing this package.

Return completed forms and all applicable attachments to

xxxxxxxxxx

(check all that apply)

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For items above marked with * indicate effective date:

*A provider agreement may not be transferred or assigned to another. However, an applicant may be joined to the provider agreement by strict compliance with the provisions of Title 22, CCR, section 51000.32 entitled “Requirements for Successor Liability with Joint & SeveralLiability.”

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Happy Tooth Dental Partnership

N/A

xxx xxx-xxxx

555 Happy Street

Anytown

Anycounty

CA

xxxxx-xxxx ✔

If the above location is leased or sub-leased complete the following information regarding the lessor and enclose a copy of your signed lease or sub-lease (including original lessor’s consent to sub-lease). If the property is privately-owned or a letter is attached proceed to question 4g.

Landlord

x years

$xxxx per month

555 Tooth St Anytown, CA xxxxx

xxx xxx-xxxx

If none check here:

https://51000.32

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-----------------------------------------------------!owners, add a separate page labeled question 13 and i nclude all information

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555 Happy Street Anytown CA xxxxx-xxxx For a change of business address, enter location moving from (if none, mark N/A and continue to question 7):

N/A

N/A

N/A

N/A

xxxxxxxxx

xxxxx

xxxxx

Name of insurance

xxxxxxx xx/xx/xxxx xx/xx/xxxx

Name of insurance

xxxxxx

xx/xx/xxxx

xx/xx/xxxx ✔

Name NPI type 1 Dental license

number Specialty Email address

Jane Doe xxxxxxxxxx xxxxx GP xxxx@youremail.com John Doe xxxxxxxxxxx xxxxx Pedo xxx@youremail.com

If none check here

FINE/DEBT AGENCY DATE ISSUED DATE TO BE PAID IN FULL

If you, the applicant/provider, are a partnership, corporation, governmental entity, or nonprofit organization, proceed to question 15

OR If you, the applicant/provider, are an unincorporated sole-proprietor proceed to question17

OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (ENTITIES)

any Attach a

separate question 16 for each entity listed below.

6

ENTITY LEGAL BUSINESSNAME

PERCENT (%) OF OWNERSHIP OR

CONTROL

Tax Identification Number (TIN)

NPI TYPE 2

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OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (ENTITIES) A

ALL

ownership and control

Within ten years from the date of this statement

Within ten years from the date of this statement,

Within ten years from the date of this statement,

(if applicable)

STATE NAME(S)

(LEGAL AND DBA) NPI AND/OR

PROVIDER NUMBER(S)

CHECK APPLICABLE PROGRAM

NPI AND/OR PROVIDER NUMBER(S)

EFFECTIVE DATE(S) OF SUSPENSION

DATE(S) OF REINSTATEMENT(S), AS APPLICABLE

If none, check here.

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OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (INDIVIDUALS)

any all

Attach a separate question 18, for each individual listed below.

NPI TYPE 1 PERCENT (%) OF Social Security OWNERSHIP OR Number (SSN)

CONTROL (Required) INDIVIDUAL NAME

xxxxxxxxxx xxx-xx-xxxx Jane Doe % xxxxxxxxx xxx-xx-xxxx John Doe %

OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (INDIVIDUALS)

Doe Jane Marie

555 South Happy Street Anytown

(Attach a current and legiblecopy.) xx/xx/xxxx xxxxxxx

CA

xxxxx-xxxx

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Jane Doe

directly

directly

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Within ten years from the date of this statement,

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Within ten years from the date of this statement,

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Within ten years from the date of this statement,

NAME(S) NPI AND/OR STATE (LEGAL AND DBA) PROVIDER NUMBER(S)

CHECK APPLICABLE PROGRAM

NPI AND/OR PROVIDER NUMBER(S)

EFFECTIVE DATE(S) OF SUSPENSION

DATE(S) OF REINSTATEMENT(S), AS APPLICABLE

ever

WHERE ACTION(S) WAS TAKEN ACTION(S) TAKEN

EFFECTIVE DATE(S) OF LICENSING AUTHORITY’SACTION(S)

WHERE ACTION(S) WAS EFFECTIVE DATE(S) OF TAKEN ACTION(S) TAKEN LICENSING AUTHORITY’SACTION(S)

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ever

WHERE ACTION(S) WAS TAKEN ACTION(S) TAKEN

EFFECTIVE DATE(S) OF LICENSING AUTHORITY’S ACTION(S)

If none, check here.

(include any fictitious business names)

EXECUTION OF THIS AGREEMENT BETWEEN AN APPLICANT OR PROVIDER HEREINAFTER JOINTLY REFERRED TO AS “PROVIDER” AND THE DEPARTMENT OF HEALTH CARE SERVICES HEREINAFTER “DHCS”, IS MANDATORY FOR PARTICIPATION OR CONTINUED PARTICIPATION AS A PROVIDER IN THE DENTI-CAL PROGRAM PURSUANT TO 42 UNITED STATES CODE, SECTION 1396a (a) (27), TITLE 42, CODE OF FEDERAL REGULATIONS, SECTION 431.107, WELFARE AND INSTITUTIONS CODE, SECTION 14043.2, AND TITLE 22, CALIFORNIA CODE OF REGULATIONS, SECTION 51000.30(a)(2).

AS A CONDITION FOR PARTICIPATION OR CONTINUED PARTICIPATION AS A PROVIDER IN THE DENTI-CAL PROGRAM, PROVIDER AGREES TO COMPLY WITH ALL OF THE FOLLOWING TERMS AND CONDITIONS, AND WITH ALL OF THE TERMS AND CONDITIONS INCLUDED ON ANY ATTACHMENT(S) HERETO, WHICH IS/ARE INCORPORATED HEREIN BYREFERENCE:

Term and Termination.

Compliance with Laws and Regulations.

National Provider Identifier (NPI).

Forbidden Conduct.

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OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (INDIVIDUALS)

any all

Attach a separate question 18, for each individual listed below.

NPI TYPE 1 PERCENT (%) OF Social Security OWNERSHIP OR Number (SSN)

CONTROL (Required) INDIVIDUAL NAME

xxxxxxxxxx xxx-xx-xxxx Jane Doe % xxxxxxxxx xxx-xx-xxxx John Doe %

OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (INDIVIDUALS)

Doe John Claude

555 South Happy Street Anytown

(Attach a current and legiblecopy.) xx/xx/xxxx xxxxxxx

CA

xxxxx-xxxx

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John Doe

directly

directly

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Within ten years from the date of this statement,

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Within ten years from the date of this statement,

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Within ten years from the date of this statement,

NAME(S) NPI AND/OR STATE (LEGAL AND DBA) PROVIDER NUMBER(S)

CHECK APPLICABLE PROGRAM

NPI AND/OR PROVIDER NUMBER(S)

EFFECTIVE DATE(S) OF SUSPENSION

DATE(S) OF REINSTATEMENT(S), AS APPLICABLE

ever

WHERE ACTION(S) WAS TAKEN ACTION(S) TAKEN

EFFECTIVE DATE(S) OF LICENSING AUTHORITY’SACTION(S)

WHERE ACTION(S) WAS EFFECTIVE DATE(S) OF TAKEN ACTION(S) TAKEN LICENSING AUTHORITY’SACTION(S)

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ever

WHERE ACTION(S) WAS TAKEN ACTION(S) TAKEN

EFFECTIVE DATE(S) OF LICENSING AUTHORITY’S ACTION(S)

If none, check here.

(include any fictitious business names)

EXECUTION OF THIS AGREEMENT BETWEEN AN APPLICANT OR PROVIDER HEREINAFTER JOINTLY REFERRED TO AS “PROVIDER” AND THE DEPARTMENT OF HEALTH CARE SERVICES HEREINAFTER “DHCS”, IS MANDATORY FOR PARTICIPATION OR CONTINUED PARTICIPATION AS A PROVIDER IN THE DENTI-CAL PROGRAM PURSUANT TO 42 UNITED STATES CODE, SECTION 1396a (a) (27), TITLE 42, CODE OF FEDERAL REGULATIONS, SECTION 431.107, WELFARE AND INSTITUTIONS CODE, SECTION 14043.2, AND TITLE 22, CALIFORNIA CODE OF REGULATIONS, SECTION 51000.30(a)(2).

AS A CONDITION FOR PARTICIPATION OR CONTINUED PARTICIPATION AS A PROVIDER IN THE DENTI-CAL PROGRAM, PROVIDER AGREES TO COMPLY WITH ALL OF THE FOLLOWING TERMS AND CONDITIONS, AND WITH ALL OF THE TERMS AND CONDITIONS INCLUDED ON ANY ATTACHMENT(S) HERETO, WHICH IS/ARE INCORPORATED HEREIN BYREFERENCE:

Term and Termination.

Compliance with Laws and Regulations.

National Provider Identifier (NPI).

Forbidden Conduct.

Nondiscrimination.

Scope of Health and Medical Care.

Licensing.

Insurance.

Record Keeping and Retention.

DHCS, AG and Secretary Access to Records; Copies of Records.

Confidentiality of Beneficiary Information.

Disclosure of Information to DHCS.

Information Regarding Subcontractors and Suppliers.

Background Check.

Unannounced Visits by DHCS, AG and Secretary.

Provider Fraud and Abuse.

Investigations of Provider for Fraud or Abuse.

Provider Fraud or Abuse Convictions and/or Civil Fraud or Abuse Liability.

Changes to Provider Information.

Prohibition of Rebate, Refund, or Discount.

Payment from Other Health Coverage Prerequisite to Claim Submission.

Beneficiary Billing.

Payment From Medi-Cal Program Shall Constitute Full Payment.

Return of Payment for Services Otherwise Covered by the Medi-Cal Program.

Compliance with Billing and Claims Requirements.

Deficit Reduction Act of 2005, Section 6032 Implementation.

Termination of Provisional Provider or Preferred Provisional Provider Status.

Provider Suspension; Appeal Rights; Reinstatement.

Automatic Suspensions/Mandatory Exclusions.

Permissive Suspensions/Permissive Exclusions.

Temporary Suspension.

Liability of Group Providers.

Legislative and Congressional Changes.

Provider Capacity.

Indemnification.

Governing Law.

Venue.

Titles.

Severability.

Assignability.

Waiver.

Complete Integration.

Amendment.

Provider Attestation.

Provider agrees that compliance with the provisions of this agreement is a condition precedent to payment to provider. The parties agree that this agreement is a legal and binding document and is fully enforceable in a court of competent jurisdiction. The provider signing this agreement warrants that he/she has read this agreement and understands it. I declare under penalty of perjury under the laws of the State of California that the foregoing information is true, accurate, and complete to the best of my knowledge and belief.

Doe Jane Marie I declare under penalty of perjury under the laws of the State of California that the foregoing information in this document, in the attachments, the disclosure statement, and provider agreement are true, accurate, and complete to the best of my knowledge and belief. I declare that I have the authority to legally bind the applicant or provider pursuant to Title 22, CCR Section 51000.30(a)(2)(B).

Partner

Anytown CA xx/xx/xxxx

Contact Person’s Information

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PRIVACY STATEMENT

Assignability.

Waiver.

Complete Integration.

Amendment.

Provider Attestation.

Provider agrees that compliance with the provisions of this agreement is a condition precedent to payment to provider. The parties agree that this agreement is a legal and binding document and is fully enforceable in a court of competent jurisdiction. The provider signing this agreement warrants that he/she has read this agreement and understands it. I declare under penalty of perjury under the laws of the State of California that the foregoing information is true, accurate, and complete to the best of my knowledge and belief.

Doe John Claude I declare under penalty of perjury under the laws of the State of California that the foregoing information in this document, in the attachments, the disclosure statement, and provider agreement are true, accurate, and complete to the best of my knowledge and belief. I declare that I have the authority to legally bind the applicant or provider pursuant to Title 22, CCR Section 51000.30(a)(2)(B).

Partner

Anytown CA xx/xx/xxxx

Contact Person’s Information

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PRIVACY STATEMENT