DRUG MEDI-CAL ORGANIZED DELIVERY SYSTEM PROVIDER FORM

INSTRUCTIONS FOR FILLING OUT THIS FORM

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the form to fill it in by hand or use a typewriter. If filling in by hand, use only blue or black ink. Do not use pencil . • Failure to provide complete and accurate information may cause your form(s) to be returned and delay processing.

• Fill out one form per request type. For example, if you are adding or removing multiple Drug Medi-Cal Organized Delivery

System (DMC-ODS) providers, you must fill out one form for each request.

• This form contains REQUIRED fields. You must fill in the information in order to submit the form. If you do not complete the required fields, the form will not allow you to save or e-mail the form. • You can click the SUBMIT button at the top of the page to e-mail the completed form back to the Master Provider File (MPF) team or click the hyperlink here -- dhcsmpf@dhcs.ca.gov.

USING THE DRUG MEDI-CAL ORGANIZED DELIVERY SYSTEM PROVIDER FORM

The DMC-ODS provider form is to be used to add or remove an existing provider on a DMC-ODS county's contracted provider list. This form can also be used to add or delete DMC-ODS treatment service codes on an existing provider's record. The provider should already have both a DMC billing number and a Data Reporting Number (DRN) (aka CalOMS/ Provider Number).

Note: The MPF Team can neither expedite nor assist in the DMC certification process. We cannot make identification changes (address, contacts, legal entity name, business name) to a DMC provider's profile; you must contact the Provider Enrollment Division for assistance at: DHCSDMCRECERT@dhcs.ca.gov.

REQUESTER INFORMATION:Submitter Name: The name of person submitting form.Submitter Phone Number: The phone number of person submitting form.County Name: Name of the county requesting to add, remove, or update a DMC-ODS provider.ODS Contract Start Date: List the effective start date of the DMC-ODS contract between the provider and the DMC-ODS County. DMC or DRN Number: Provide either the provider's 4-digit DMC billing number or 6-digit DRN (aka CalOMS/ Provider Number). Site National Provider Identification (NPI) Number: The NPI number the provider will use to submit claims.Verify Provider is Not Excluded: Please indicate that you have verified the providers who are employed or contracted with this facility are not on any excluded list (OIG, etc.).

IDENTIFICATION FIELDS: Provider Name (DBA): The provider's business name (DBA/ doing business as). Please note: This must be the DBA, as many legal entities have multiple provider facilities.Service Location Address: Address of the facility where the services are provided (not the administrative or corporate address). Please note: This must be a physical address, P.O. Boxes are not acceptable.Service Location Zip Code: A 9-digit Zip Code using this format 00000-1111.DMC-ODS Treatment Service Codes: Select the DMC-ODS treatment service codes the provider is contracted to provide. If updating the DMC-ODS treatment service codes on an existing provider's record, please use the note section to specify which codes are being added or deleted.Residential License Number: If providing Residential and/or Detox services, include the provider's Residential License Number and/or Detox Certification Number. MPF Analyst Information: Please leave these fields blank. The MPF analyst will populate these fields prior to sending back completed request.

DRUG MEDI-CAL ORGANIZED DELIVERY SYSTEM PROVIDER FORMPLEASE READ THE INSTRUCTIONS PROVIDED ABOVE BEFORE FILLING OUT THIS FORM This form requires the free Adobe Acrobat Reader softwareDownload it here: https://get.adobe.com/reader/

The MPF Team can neither expedite nor assist in the DMC certification process. We cannot make identification changes to a DMC provider's profile; you must contact the Provider Enrollment Division for assistance at: DHCSDMCRECERT@dhcs.ca.gov

Requester Information - Required

Submitt er Name

Submitter Phone

County Name ODS Contract Start Date

DMC or DRN number

National Provider ID (NPI)

Is Provider Excluded YES NO

In the fields below, please enter the contact information for the DMC-ODS provider

Business Name (DBA/Doing Business As)

Service Location Address (Mailing/Site)

City State Zip Code

Service Location Phone Number

NOTES:

DMC-ODS Treatment Service Codes (Choose All That Apply)

91- ODS Outpatient Drug-Free (ODF) Individual

92 - ODS Outpatient Drug-Free (ODF) Group

105 - ODS Intensive Outpatient Treatment (IOT)

106 - ODS Partial Hospitalization (PH)

120 - ODS Narcotic Treatment ProgramMethadone - All Programs (NTP)

(Choose all that apply)

NonPerinatal Perinatal

107- ODS Withdrawal Management (WM) 1

108 - ODS Withdrawal Management (WM) 2

109 - ODS Withdrawal Management (WM) 3.2

112 - ODS Residential (RES) 3.1

113 - ODS Residential (RES) 3.3

114 - ODS Residential (RES) 3.5

(Choose all that apply)

NonPerinatal Perinatal

Residential License NumberRequired if provider is offering Residential and/ or Detox Services

Request Completed By

Date Request Completed

MPF Analyst Information(MPF Staff Use Only)