Contract Application Instructions:

A W-9 form is required to identify the contracting entity before contract issuance. W-9 must accompany Contract Application.

Please return application electronically as a Microsoft Word document or PDF to Daphyne Watson, Contracting Manager, at dwatson@chgsd.com (FAXED COPIES WILL NOT BE ACCEPTED). For questions regarding the application, please contact Maria Diaz at (619) 498-6560.

*ALL APPLICABLE FIELDS MUST BE COMPLETED.

If seeing patients under the age of 21 years, please apply to CCS.

http://www.dhcs.ca.gov/services/ccs/Pages/ProviderEnroll.aspx

REQUESTED BY: PROVIDER CHG	NOTE:
A. CONTACT INFORMATION
DATE:	CONTACT E-MAIL:
CONTACT NAME:	TITLE:
CONTACT PHONE #:	CONTACT FAX #:
B. PROVIDER/GROUP INFORMATION
ORGANIZATION NAME: ORGANIZATION NPI #:	DBA:
OFFICE NAME: (If different than organization name)
PROVIDER NAME(S):	SPECIALTY: Hospice Services
SUBSPECIALTY:
TAX ID #:	NPI #:	Billing NPI #:	CAQH #:
ADDRESS(ES):	LANGUAGE(S) SPOKEN BY PROVIDER(S):
PHONE #:	FAX #:
MEDI-CAL PROGRAM ENROLLED? YES NO MEDICARE PROGRAM ENROLLED? YES NO	TREATS PATIENTS <18: YES NO TREATS PATIENTS 18 AND OVER YES NO (Must be CCS paneled if seeing patients under age 21)
CALIFORNIA CHILDREN SERVICES (CCS) PANELED? YES NO N/A	CONTRACT: New Add LINE(S) OF BUSINESS: Medi-Cal CommuniCare Advantage (HMO D-SNP) Community y Más (HMO C-SNP)
CONTRACT TYPE: Ancillary Facility Allied Other	ACCEPT STANDARD RATES? YES NO (Medi-Cal Rates for Medi-Cal patients) (Medicare Rates for CMC patients)
AGE RESTRICTIONS:	HOURS OF OPERATION:
SCOPE OF SERVICES:
OFFER GENDER-AFFIRMING SERVICES: YES NO
VIDEO TELEHEALTH: YES NO	PHONE TELEHEALTH: YES NO
C. FACILITY CREDENTIALING STATUS (FOR FACILITIES ONLY)
IS FACILITY CREDENTIALED? YES NO N/A	STATE LICENSE #:
IS FACILITY ACCREDITED? YES NO N/A	IF YES, BY WHICH AGENCY?
D. ELECTRONIC DATA INTERCHANGE (EDI)
DOES PROVIDER USE A PRACTICE MANAGEMENT SYSTEM? YES IF YES, WHICH ONE? NO	BILLING SERVICE CONTACT INFORMATION: CONTACT NAME: E-MAIL: PHONE #: FAX #:
EDI READY (ANSI 837 FORMAT)? YES NO
UPON CONTRACT APPROVAL, ACCEPTANCE OF PAYMENT VIA EFT (Electronic Funds Transfer) WILL BE REQUIRED
ARE YOU INTERESTED IN SUBMITTING CLAIMS DIRECTLY TO CHG? YES NO (If no, complete following question) CLEARINGHOUSE NAME (If any):
FOR CHG USE ONLY
DIRECTOR APPROVED: YES NO	NETWORK COMMITTEE RECOMMENDATION YES NO	PRE-CRED: YES NO
COO APPROVED: YES NO Initials:__________ Date:________________	OPS INFORMED: YES NO Date:_________________