Optometrist Application Package Instructions
Optometrists yuav tsum xa lawv tus kheej thiab/lossis cov ntawv thov pab pawg ntawm PAVE (Kev Pabcuam Kev Pabcuam thiab Kev Pabcuam rau Kev Sau Npe). Yog tias koj tab tom xa ib daim ntawv thov pab pawg, thov xyuas kom koj xa tsawg kawg ob daim ntawv thov kev ua haujlwm hauv PAVE txhawm rau tsim koj pab pawg.
Daim ntawv tso cai
Ua ntej thov rau Medi-Cal, ua ntej kos lub California Pawg Saib Xyuas Kev Pom Zoo lub vev xaib kom ntseeg tau tias koj ua tau raws li tag nrho cov ntawv tso cai.
Cov ntaub ntawv xav tau
Tom ntej no, sau cov ntaub ntawv xav tau hauv qab no, raws li tsim nyog, txhawm rau muab lawv tso rau hauv PAVE thaum koj ua tiav koj daim ntawv thov PAVE. Thov xyuas kom meej tias cov ntaub ntawv uas tau muab tso tawm yog pom tseeb.
1. California Optometric License
2. To enroll at a business location that you own in addition to your “principal place of practice,” you must also submit a Branch Office License for that location. Note: The business address of the applicant or provider on the application must exactly match the business address on the branch office license.
3. If you are employed as an optometrist, you must submit a Statement of Licensure for each location where you practice optometry in addition to the “principal place of practice.”
4. Daim Ntawv Tso Cai Tsav Tsheb lossis daim npav qhia tawm hauv lub xeev (tso tawm hauv 50 Tebchaws Meskas lossis Cheeb Tsam ntawm Columbia) ntawm tus neeg muab kev pabcuam, lossis tus neeg kos npe rau daim ntawv thov uas muaj txoj cai khi rau tus neeg thov lossis tus neeg muab kev pabcuam. Daim ntawv kos npe yuav tsum yog tus muab kev pabcuam, tshwj tsis yog tus neeg muab kev pabcuam yog lub koomhaum. Yog tias tus kws kho mob yog ib lub tuam txhab thiab daim ntawv thov yuav raug kos npe los ntawm ib tus neeg uas tsis yog tus muab kev pabcuam, thov xa ib daim ntawv theej ntawm ntu ntawm lub tuam txhab txoj cai lij choj uas txheeb xyuas tus neeg kos npe txoj cai rau kev cai lij choj lub koom haum.
5. Tsoom Fwv Teb Chaws Tus Neeg Ua Hauj Lwm Tus Naj Npawb (FEIN) lossis Tus Naj Npawb Tus Neeg Them Se (ITIN) kev txheeb xyuas, yog tias tsis siv tus lej social security, los ntawm kev xa daim ntawv tam sim no Internal Revenue Service (IRS) generated. Tsuas yog cov ntaub ntawv lees paub muaj xws li IRS-tsim Tsab Ntawv 147-C, IRS-tsim Daim Ntawv 941 (Tsuas Ua Haujlwm Lub Peb Hlis Federal Tax Return), IRS-tsim Daim Ntawv Foos 8109-C (Daim Coupon Deposit), lossis IRS-tsim Daim Ntawv SS-4 (tsuas yog Daim Ntawv Pom Zoo/Kev Qhia Txog Tus Kheej). Nco tseg: Lub npe raug cai ntawm tus neeg thov lossis tus neeg muab kev pabcuam hauv daim ntawv thov yuav tsum ua raws nraim lub npe ntawm IRS-tsim cov ntaub ntawv; thiab tus neeg thov kev pab yuav tsum yog tus tswv lossis tus tub ceev xwm ntawm lub chaw teev npe hauv daim ntawv IRS. Yog xav paub ntxiv, thov mus ntsib IRS lossis hu rau lawv ntawm (800) 829-4933.
6. 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 the application 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, click on the “California’s Counties” link, and select “County Web Sites.”
7. Fictitious Name Permit (FNP) issued by the California Board of Optometry, if using a fictitious name for your optometry practice, as defined by the Board. Note: The business name of the applicant or provider on the application, all local business licenses/permits, and the FNP must exactly match. For further information, visit the Optometry Board Web site and click on the “Licensing Information” link and scroll down to “Fictitious Name Permit”.
8. Daim Ntawv Tso Cai Muag Khoom uas tau muab los ntawm California State Board of Equalization, yog muaj. Nco tseg: Lub npe lag luam thiab chaw nyob ua lag luam ntawm tus neeg thov lossis tus neeg muab kev pabcuam hauv daim ntawv thov yuav tsum phim lub npe lag luam thiab chaw nyob ua lag luam ntawm tus muag daim ntawv tso cai. Yog xav paub ntxiv, hu rau Pawg Neeg Saib Xyuas Kev Ncaj Ncees ntawm (916) 445-6362.
9. Ua tiav Daim Ntawv Pom Zoo Koom Tes Ua Haujlwm, yog tias koj lub lag luam yog kev koom tes. Kev ua haujlwm qeeb yuav raug zam los ntawm kev qhia seb lub koom haum puas yog General Partnership lossis Limited Partnership thiab tseem xa cov hauv qab no:
a) Rau General Partnership, ib daim ntawv teev npe ntawm txhua tus neeg koom tes nrog feem pua ntawm cov tswv cuab lossis tswj cov paj laum rau txhua tus; los yog
b) Rau Kev Koom Tes Ua Lag Luam Txwv, cov ntaub ntawv txheeb xyuas tus khub General, thiab cov npe ntawm txhua tus neeg koom tes nrog feem pua ntawm cov tswv cuab lossis tswj kev txaus siab rau txhua tus.
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 and click on the “California Business Search” link or other appropriate link.
10. 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 and click on the “California Business Search” link or other appropriate link.
11. Certificate of Commercial Liability Insurance (kev lag luam, kev ua lag luam, lossis kev lav phib xaub, lossis kev tuav pov hwm hauv chaw ua haujlwm) hauv tus nqi tsis pub tsawg dua $ 100,000 rau ib daim ntawv thov thiab qhov tsawg kawg nkaus txhua xyoo ntawm $ 300,000. Kev lees paub lees paub yog pov thawj ntawm kev tuav pov hwm tus kheej, lossis daim ntawv pov thawj ntawm kev tuav pov hwm lossis daim ntawv tshaj tawm uas muab los ntawm lub tuam txhab pov hwm uas muaj lub npe ntawm lub tuam txhab pov hwm, lub npe thiab chaw nyob ua lag luam ntawm cov ntawv pov hwm, hnub siv tau, thiab kev txwv ntawm kev pov hwm. Nco tseg: Lub npe thiab chaw nyob ua lag luam, suav nrog tus lej suite yog tias tsim nyog, ntawm tus neeg thov lossis tus neeg muab kev pabcuam hauv daim ntawv thov yuav tsum ua raws nraim li daim ntawv pov hwm lub npe thiab chaw nyob ntawm daim ntawv pov thawj ntawm kev tuav pov hwm lossis daim ntawv tshaj tawm.
12. Certificate of Professional Liability Insurance nyob rau hauv ib tug npaum li cas ntawm tsis tsawg tshaj li $100,000 ib daim ntawv thov thiab ib tug tsawg kawg nkaus txhua xyoo tag nrho ntawm $300,000. Kev lees paub lees paub yog daim ntawv pov thawj ntawm kev tuav pov hwm lossis daim ntawv tshaj tawm uas muab los ntawm lub tuam txhab pov hwm uas muaj lub npe ntawm lub tuam txhab pov hwm, lub npe ntawm cov ntawv pov hwm, hnub siv tau, thiab kev txwv ntawm kev pov hwm. Nco tseg: Tus kws kho mob lub npe, raws li nws tshwm nyob rau hauv California Optometric Licence, yuav tsum tau qhia nyob rau hauv kev txheeb xyuas ntawm kev pov hwm kev lav phib xaub.
13. Certificate of Workers 'Compensation Insurance yog xav tau los ntawm California txoj cai lij choj, yog tias koj lub lag luam muaj ib lossis ntau tus neeg ua haujlwm. Kev lees paub lees paub yog pov thawj ntawm kev tuav pov hwm tus kheej, lossis daim ntawv pov thawj ntawm kev tuav pov hwm lossis daim ntawv tshaj tawm uas muab los ntawm lub tuam txhab pov hwm uas muaj lub npe ntawm lub tuam txhab pov hwm, lub npe thiab chaw nyob ua lag luam ntawm cov ntawv pov hwm, thiab hnub siv tau. Yog tias tsis muaj kev pov hwm them nyiaj rau Cov Neeg Ua Haujlwm, yuav tsum muaj lus piav qhia. Nco tseg: Lub npe thiab chaw nyob ua lag luam ntawm tus neeg thov lossis tus neeg muab kev pabcuam yuav tsum ua raws nraim li cov ntawv pov hwm lub npe thiab chaw nyob ntawm daim ntawv pov thawj ntawm kev pov hwm.
14. Kos Npe Daim Ntawv Pom Zoo, yog tias qhov chaw ua lag luam tsis yog los ntawm tus neeg thov lossis tus muab kev pabcuam. Nco tseg: Lub npe thiab chaw nyob ua lag luam ntawm tus neeg thov lossis tus neeg muab kev pabcuam yuav tsum ua raws nraim li tus neeg xauj tsev lub npe thiab chaw nyob ntawm daim ntawv cog lus xauj tsev.
15. Kev lav phib xaub ua tiav nrog Daim Ntawv Pom Zoo Sib Koom thiab Ntau Daim Ntawv Pom Zoo (DHCS 6217), yog tias muaj.