Registration Guidance
Hospital and Skilled Nursing Facility COVID-19 Worker Retention Payments
Covered Entities (CEs), Covered Services Employers (CSEs), and Physician Group Entities (PGEs) are all required to register with the Department of Health Care Services (DHCS) in order to participate in the Hospital and Skilled Nursing Facility COVID-19 Worker Retention Payments (WRP). Once registered, CEs, CSEs, and PGEs will be approved to apply for retention payments on behalf of eligible workers.
General Guidance:
Registration opens on October 21, 2022, and closes on December 21, 2022. CEs, CSEs, and PGEs are encouraged to complete registration early to avoid delays in approval.
A link to the registration form will be available on the
Hospital and Skilled Nursing Facility COVID-19 Worker Retention Payments webpage on October 21.
All entities must complete and submit a
Form STD 204, Payee Data Record at time of registration, even if one is already on file with the State of California.
If you are part of a large network, health system, or medical group, you can register using information from your largest facility/organization (with the largest number of workers) and register once.
Covered Services Employers (see definition below) will be asked to upload electronic copies of your signed Service Contract Agreement(s) with Covered Entities/Qualifying Facilities either in Word (doc, docx) or PDF format. The system accepts one combined file with a maximum file size of 16 MB.
With the exception of independent physicians, workers should not apply directly. Qualified facilities, employers, and physician groups are responsible for requesting retention payments for their qualified workers and physicians.
Depending upon entity type, there are approximately 15 items to be completed on the registration form. Please see Appendix for required information.
Approximate completion time is 15 minutes.
Things to know before you get started:
Keep your browser open until you have completed registration.
Closing your browser prior to completion will require you to start the registration from the beginning.
You must click 'Next' on most pages to continue to the next page.
You can return to the previous page by clicking 'Prev'.
To start the registration process, you'll be required to accept the following Disclosure and Privacy Statements before proceeding.
Disclosure of Personal Information. In order to validate identity and qualification for participation in WRP, it may be necessary to share information you provide with authorized state/federal agencies or third-party vendors. While it is your choice to complete the registration and application process, failure to complete the entire process will result in the inability to determine eligibility and make corresponding retention payments.
Privacy Notice, Civ. Code Section 1798.17: The personal information collected on and with this form is confidential, subject to the Department of Health Care Services (DHCS) Notice of Privacy Practices that can be found here:
https://www.dhcs.ca.gov/formsandpubs/laws/priv/Documents/Notice-of-Privacy-Practices-English.pdf. DHCS requires the information to administer WRP. DHCS will not use or share the information for other purposes except with your permission or as permitted by law. You must provide all information requested on this form. If you do not provide all information requested, we may be unable to determine if you qualify for payment. In most cases, the individual(s) for whom this information pertains has the right to access it. DHCS is authorized to collect this information pursuant to Labor Code Section 1492. This privacy notice is required by California Civil Code Section 1798.17.
I understand and consent that all information provided on the WRP - Covered Entity and Covered Services Employers Registration Form may be shared.
- To complete the registration, you will be asked to confirm the information you have entered and consent to the attestation by entering your first and last name and your title within the organization, and then click the done button. A successful submission response will be provided with further instructions.
I declare under penalty of perjury under the laws of the State of California that the foregoing information in this document and any attachments is true, accurate, and complete to the best of my knowledge and belief. I am authorized to submit this information on behalf of the applicant. I understand by typing the first and last name in the box below constitutes my electronic signature.
Note: The authorized attestor must be a sole proprietor, partner, corporate officer, or an official representative of entity/organization who has the authority to legally bind the applicant.
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After registration submission, CEs, CSEs, and PGEs will receive an email from DHCS confirming that their registration has been accepted or that additional information is required.
Selecting your entity type:
Information required on the registration form is based on entity type. Be sure to select the entity type that best reflects your organization. If you have more than one entity type described below with the same Name, Tax Identification Number (TIN), or Federal Employer Identification Number (FEIN), select the entity type with the largest group of employees.
Physician Entity - Independent Physician or Physician Group. Any legal entity that contracts with a qualifying facility to provide physician services, including, but not limited to, professional medical corporations and individual physicians/sole proprietorships.
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Covered Services Employer - Any person or entity who directly employs or exercises control over the wages, hours, or working conditions of any person; and provides onsite services, such as clerical, dietary, environmental services, laundry, security, engineering, facilities management, administrative, or billing staff through a
contract with the qualifying facility where the person or entity is the employer of record.
Definitions:
If your Entity Type is “Qualifying Facility"
You will be required to select one of the following facility types:
| Acute Psychiatric Hospital | As defined in
Health and Safety Code section 1250(b). |
| General Acute Care Hospital | As defined in
Health and Safety Code section 1250(a). |
Skilled Nursing Facility
| As defined in
Health and Safety Code section 1250(c). |
Other Health Clinic
| Affiliated, owned, or controlled by a person or entity that owns or operates an acute care hospital as defined above, and operated by a nonprofit corporation that conducts medical research and provides health care to patients through a group of 40 or more physicians and surgeons, who are independent contractors representing not less than 10 board certified specialties, and not less than two-thirds of whom practice on a full-time basis at the clinic, as set forth in
Health and Safety Code section 1206(l).
|
Other Registration Form Terms Defined
Contact Person (used for Contact Name, Contact email address, and Contact Phone Number)
| The contact person should be the individual who DHCS may contact, if needed, regarding your registration form.
The email address will be used for all DHCS correspondence regarding your registration status and next steps including application.
|
| NPI | National Provider Identifier: a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare & Medicaid Services (CMS). |
| Facility License Number | The 9-digit number assigned by the California Department of Public Health (CDPH). |
| California Medical License Number | The identification number associated with the occupational license that permits a person to legally practice medicine as issued by the Medical Board of California. |
| Business License Number | The identification number associated with the license that allows you to conduct business. |
| TIN/FEIN | Tax Identification Number or Federal Employer Identification Number: a federal identification number that appears on your W-9 form. |
Payee Entity Type (as defined by the State of California – Department of Finance) |
Sole Proprietor/Individual: Individual * Sole Proprietor * Grantor (Revocable Living) Trust disregard for federal tax purposes.
Single Member LLC – owned by an individual: Limited Liability Company (LLC) owned by an individual and is disregarded for federal tax purposes.
Partnerships: Partnerships * Limited Liability Partnerships (LLP) * and, LLC treated as a Partnership.
Estate or Trust: Estate * Trust (other than disregarded Grantor Trust).
Corporation – Medical: Corporation that is a medical in nature (e.g., medical and health care services, physician care, nursery care, dentistry, etc.) * LLC that is to be taxed like a corporation and is a medical in nature.
Corporation – Legal: Corporation that is legal in nature (e.g., services of attorneys, arbitrators, notary publics involving legal or law related matters, etc.) * LLC that is to be taxed like a corporation and is legal in nature.
Corporation – Exempt: Corporation that qualifies for an Exempt status, included 501(c) 3 and domestic non-profit corporations.
Corporation – All Others: Corporation that does not meet the qualifications of any of the other corporation types listed above * LLC that is to be taxed as a corporation and does not meet any of the other corporation types listed above. |
Payee Residency Status |
California Resident: Qualified to do business in California or maintains a permanent place of business in California.
California Nonresident: You are considered nonresident if your permanent place of business is outside of California. Payments to nonresidents for services may be subject to state income tax withholdings. |
For more information, please visit the
Hospital and Skilled Nursing Facility COVID-19 Worker Retention Payments webpage and review the Frequently Asked Questions (FAQs) and Glossary of Terms.
Appendix: Required Information
The following information is required on the registration form.
Covered Entities (Qualifying Facilities):
- Facility type
- Facility name or business/legal name associated with the Taxpayer Identification Number (TIN)/ Federal Employer Identification Number (FEIN) (as it appears on the IRS form W9)*
- Address (as it appears on the IRS form W9)*
- Facility license number (CDPH assigned 9-digit number)*
- TIN or FEIN
- Payee entity type
- Payee residency status (California resident or California nonresident)
- Contact name (first and last)
- Contact email address and phone number
- Estimated number of qualifying personnel
- National Provider Identification (NPI) number
- Name(s) of contracted Covered Services Employers providing onsite services
- Name(s) of affiliated Physician Entities providing onsite services
- Completed
STD 204 (Payee Data Record) form
- Attester Name and Title
*These fields will automatically populate with preset information in the drop-down menu. To manually input information, select the first option in the drop-down.
Covered Services Employers:
- Name (first and last) or business/legal name associated with the TIN/FEIN (as it appears on the IRS form W9)
- Address (as it appears on the IRS form W9)
- TIN or FEIN
- Payee entity type
- Payee residency status (California resident or California nonresident)
- Contact name (first and last)
- Contact email address and phone number
- Estimated number of qualifying personnel
- Names(s) of qualifying facilities served onsite (medical facilities you are in contract with and which meet the requirements cited in the FAQs) and types of services provided at onsite locations
- Digital upload of relevant portions of contract agreement with Covered Entities, including scope of work and signature page
- Completed
STD 204 (Payee Data Record) form
- Attester name and title
Physician Group Entities (or Independent Physicians):
- Physician name (first and last) or business/legal name associated with the TIN/FEIN (as it appears on the IRS form W9)
- Address (as it appears on the IRS form W9)
- TIN or FEIN
- Payee entity type
- Payee residency status (California resident or California nonresident)
- Contact name (first and last)
- Contact email address and phone number
- Estimated number of qualifying personnel
- NPI number
- Physician/medical license number (license number to perform business in California, if individual)
- Name(s) of qualifying facilities where services are rendered
- Completed
STD 204 (Payee Data Record) form
- Attester name and title
