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Nurse Practitioner Application Package Instructions

You need to complete three separate Medi-Cal forms and attach a number of required documents as verification of information provided in the Medi-Cal forms. All questions and blanks on the forms must be completed. Also, legible and current copies of all required documents must be submitted in order for the application package to be considered complete. An incomplete application package will prolong your enrollment process because it will be returned to you for correction and/or completion. The Provider Enrollment staff can not make any changes to your documents.

If you are forming a new Nurse Practitioner Group or joining an existing Medi-Cal enrolled Nurse Practitioner Group, go back and select "Group Provider Package" and use the DHCS 6203 application for enrolling the Group and DHCS 6216 applications to enroll the individual rendering practitioners.

If you are joining an existing Medi-Cal enrolled Medical Group, you will use the DHCS 6248 application form. Doctors of medicine, doctors of osteopathy, physician assistants and nurse practitioners may be combined in a medical group for enrollment purposes.

If you are enrolling as an individual ‘stand alone’ provider, you need to use the DHCS 6204 application to enroll.

Licensing

Prior to applying to Medi-Cal, first check California Board of Registered Nursing Web site at www.rn.ca.gov  to ensure you meet all the licensing requirements shown on their links, "Regulations", "Practice Information", then "Nurse Practitioner".

Required Documents listed below are for Both DHCS 6204 and DHCS 6248 Application Forms, unless otherwise stated-- Make legible copies of current documents that are required to be submitted with your Medi-Cal application forms, as listed below.

1. California Registered Nurse License and Certificate of Nurse Practitioner from a national or state organization acknowledged by California Board of Registered Nursing, and specifying the area of specialization training.

2. For DHCS 6248 Application Only: California Medical License of the applicant’s supervising physician and California Medical License of the applicant’s employing provider, if applicable and if different than the supervising physician.

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3. Driver’s License or state-issued identification cards (issued within the 50 United States or the District of Columbia) for each of the following;

a. The Certified Nurse Practitioner Applicant

b. For DHCS 6248 application only: The supervising physician's driver license or state-issued identification card. 

c. For DHCS 6248 application only: The person signing the form for the Employing Provider. The signature must be that of the employing provider, unless the provider is a corporation, governmental entity or non-profit organization. If the employing provider is one of these three entity types and the forms are going to be signed by a person other than the employing provider, please submit documentation that identifies the signing person’s authority to legally bind the corporation or non-profit organization or to represent the governmental entity.

4. For DHCS 6248 Application Only: Certified Nurse Practitioner’s Verification of Employment

5. National Plan and Provider Enumeration System (NPPES) confirmation for each National Provider Identifier (NPI) you list in the application package. Acceptable NPI documentation is one of the following: 1) NPI notification letter from the NPPES, 2) NPI notification e-mail from NPPES, or 3) NPI notification letter or e-mail from the Electronic File Interchange Organization (EFIO). Note: The name and business address of the applicant or provider on all forms must exactly match the name and practice location on the NPPES or EFIO notification. For information on how to apply for an NPI or update your information in NPPES, visit the Medi-Cal Web site at www.medi-cal.ca.gov, and click on the "NPI" link, or go to https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart.

6. Federal Employer Identification Number (FEIN) or Individual Taxpayer Identification Number (ITIN) verification, if a social security number is not used, by submitting a current Internal Revenue Service (IRS) generated document. The only acceptable documents include an IRS-generated Letter 147-C, IRS-generated Form 941 (Employer’s Quarterly Federal Tax Return), IRS-generated Form 8109-C (Deposit Coupon), or IRS-generated Form SS-4 (only the official Confirmation Notification of FEIN/ITIN assignment). Note: The legal name of the applicant or provider on all forms must exactly match the name on the IRS-generated document; and the applicant/provider must be an owner or officer of the entity listed on the IRS document. For further information, please contact the IRS at (800) 829-4933 or www.irs.gov.

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7. Certificate of Professional Liability Insurance in an amount of not less than $100,000 per claim and a minimum annual aggregate of $300,000. Acceptable verification is a certificate of insurance or declaration sheet issued by the insurance company that contains the name of the insurance company, the name of the insured, effective dates, and limits of coverage. Note: The provider’s name, as it appears on the California Registered Nurse License and Nurse Practitioner Certificate, must also show on the verification of the professional liability insurance.

8. For DHCS 6204 Application Only: Certificate of Commercial Liability Insurance (business, general, or comprehensive liability, or office premises insurance) in an amount of not less than $100,000 per claim and a minimum annual aggregate of $300,000. Acceptable verification is either evidence of being self-insured, or a certificate of insurance or declaration sheet issued by the insurance company that contains the name of the insurance company, the name and business address of the insured, effective dates, and limits of coverage. Note: The name and business address, including suite number if applicable, of the applicant or provider on all forms must exactly match the insured’s name and address on the certificate of insurance or declaration sheet.

9. For DHCS 6204 Application Only: Certificate of Workers’ Compensation Insurance is required by California law, if your business has one or more employees. Acceptable verification is either evidence of being self-insured, or a certificate of insurance or declaration sheet issued by the insurance company that contains the name of the insurance company, the name and business address of the insured, and effective dates. If no Workers’ Compensation insurance is required, an explanation must be provided. Note: The name and business address of the applicant or provider must exactly match the insured’s name and address on the certificate of insurance.

10. For DHCS 6204 Application Only: Signed Lease Agreement, if business premises are not owned by the applicant or provider. Note: The name and business address of the applicant or provider must exactly match the lessee’s name and address on the lease agreement.

11. For DHCS 6204 Application Only: Local Business License, Tax Certificate, and Permit for any city and/or county where business activities are conducted. Note: The name and business address of the applicant or provider on all forms must exactly match the business name and business address on all local licenses and permits. If a business license/permit is not required, please submit a written statement from your local city/county indicating that your business does not require any license or permit. For further information, please contact your city business license office and/or visit the California State Association of Counties Web site at www.csac.counties.org, click on the "California’s Counties" link, and select "County Web Sites."

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12. For DHCS 6204 Application Only: Recorded/stamped Fictitious Business Name Statement (FBNS), issued by the county where the principal place of business is located, if using a fictitious business name AND the business name is different from the legal name on your application. For example, in the case of a corporation, any name other than the corporation name on record with the Secretary of State requires a FBNS. Note: The business name and business address of the applicant or provider on all forms, all local business licenses/permits, and the FBNS must exactly match. To determine the applicable county agency where fictitious business names are filed, please visit the California State Association of Counties Web site at www.csac.counties.org, click on the "California’s Counties" link, and select "County Web Sites.

13. For DHCS 6204 Application Only: If your business is a corporation, processing delays may be avoided by attaching a copy of the filed Articles of Incorporation from the Secretary of State, and a list of directors’ and officers’ names and titles, with percent of ownership and control interest for each.

To verify or change the name and/or status of your corporation or for further information, please visit the Secretary of State California Business Portal Web page at www.sos.ca.gov/business/business.htm, and click on the "California Business Search" link or other appropriate link.

14. For DHCS 6204 Application Only: If your business is a partnership, a fully executed Partnership Agreement. Processing delays may be avoided by indicating whether the entity is a General Partnership or Limited Partnership and also submitting the following:

a) For a General Partnership, a list of all partners with percent of ownership or control interest for each; or

b) For a Limited Partnership, information identifying the General Partner and a list of all partners with percent of ownership or control interest for each.

To verify or change the name and/or status of your partnership or for further information, please visit the Secretary of State California Business Portal Web page at www.sos.ca.gov/business/business.htm, and click on the "California Business Search" link or other appropriate link.

15. For DHCS 6204 Application Only: Successor Liability with Joint and Several Liability Agreement (DHCS 6217), if applicable. For further information on using successor liability, visit the Medi-Cal Web site at www.medi-cal.ca.gov, and click on the "Provider Enrollment" link, then "Statutes, Regulations and Provider Bulletins, " and then select the Provider Bulletins entitled "Important Reminder: Providers Selling or Purchasing a Business" and "Requirements and Procedures for Successor Liability."

You may need to submit additional documents depending upon answers to certain questions on the Medi-Cal Disclosure Statement (DHCS 6207). The document requirements are subject to change depending upon future changes in enrollment regulations and/or state law.

PROCEED TO THE 3 APPLICATION FORMS NEEDED

1. Medi-Cal Nonphysician Medical Practitioner and Licensed Midwife Application Form (DHCS 6248), if joining medical group

OR

2. Medi-Cal Provider Application (DHCS 6204), if applying as individual

AND

3. Medi-Cal Disclosure Statement Form (DHCS 6207)

AND

4. Medi-Cal Provider Agreement Form (DHCS 6208)