HPSM Pre-Screening Roster
Please upload a complete HPSM pre-screening roster template. The template is required for provider groups or clinics with more than 2 physicians/providers.
The pre-screening roster template can be downloaded here.
Proof of Medi-Cal Enrollment
To expedite the review process please upload proof of Medi-Cal enrollment, such as
a letter from DHCS, another Managed Care Plan, and/or CMS/Noridian. Proof must be shown for each physician that renders to a group practice.
Proof of Medicare Enrollment
To expedite the review process please upload proof Medicare enrollment, such as
a letter from DHCS, another Managed Care Plan, and/or CMS/Noridian. Proof must be shown for each physician that renders to a group practice.
Provider Information
Additional Provider Information