Provider Registration for Claims Submission
☐ Group with Practitioner(s)
Group Billing NPI
Provider State License
Tax ID Number
Forward completed form along with a W-9 to Provider Data Management Services
via fax at 714-954-2330 or email to email@example.com.
All completed requests received will be processed within seven business days.
If you have any questions, contact the Provider Data Management Services at 714-246-8468.
All calls will be returned within one business day.
If approved for COVID 19 Emergency Medi-Cal Provider Enrollment, please include the
Department of Health Care Services (DHCS) approval letter.
Provider Data Management Services