How does a dental provider notify Denti-Cal of a Change of Ownership?
Changes in ownership (or control interest) of less than 50 percent or more require submission of a Medi-Cal Supplemental Changes (form DHCS 6209) and a Medi-Cal Disclosure Statement (form DHCS 6207). In addition, changes in ownership (or control interest) of 50 percent or more of an enrolled provider require submission of a complete application. For individual practices, submit a new enrollment application package consisting of the Medi-Cal Provider Application (form DHCS 6204), the Medi-Cal Disclosure Statement (form DHCS 6207) and the Medi-Cal Provider Agreement (DHCS 6208). For group practices, submit the Medi-Cal Group Application (form DHCS 6203), the Medi-Cal Disclosure Statement (form DHCS 6207) and the Medi-Cal Provider Agreement (form DHCS 6208) along with all required attachments.
