Application For Medi-Cal Certification As A Primary Care Clinic Provider {HS 269}

HS 269, APPLICATION FOR MEDI-CAL CERTIFICATION AS A PRIMARY CARE CLINIC PROVIDER, this form is used for primary care clinics submitting an initial change of ownership or a report of change application to the centralized application branch that would like to participate in the Medi-Cal program. A State license is required to operate a "community" or "free" Primary Care Clinic (PCC) in California, which are defined as: A community clinic is "a clinic operated by a tax-exempt nonprofit corporation that is supported and maintained in whole or in part by donations, bequests, gifts, grants, government funds or contributions that may be in the form of money goods, or services. In a community clinic, any charges to the patient shall be based on the patient's ability to pay, utilizing a sliding scale," pursuant to Health and Safety Code (HSC) section 1204(a)(1)(A). A free clinic is "a clinic operated by a tax-exempt nonprofit corporation supported in whole or in part by voluntary donations, bequests, gifts, grants, government funds or contributions that may be in the form of money, goods, or services. In a free clinic there shall be no charges directly to the patient for services rendered or for drugs, medicines, appliances, or apparatuses furnished," pursuant to HSC section 1204(a)(1)(B). www.FormsWorkflow.com