Tus Kws Kho Mob-Owned Surgery Center lossis Surgical Clinic Application Information
If your surgery center does not have any percentage of ownership by physicians, then you need to contact the California Department of Public Health’s Licensing and Certification Division for information regarding enrolling as a Medi-Cal provider, instead of enrolling through PED.
Cov Kws Kho Mob-Owned Surgery Centers thiab Surgical Clinic Providers yuav tsum xa lawv cov ntawv thov rau ib tus neeg thiab/lossis pab pawg ntawm PAVE (Cov Ntawv Thov Kev Pabcuam thiab Kev Pov Hwm rau Kev Sau Npe).
Tus nqi thov
Effective January 1, 2013, applicants requesting enrollment as a Physician-Owned Surgery Center or Surgical Clinic are subject to payment of an application fee upon submission of their application. The Medi-Cal Application Fee Requirements for Compliance with 42 Code of Federal Regulations Section 455.460Regulatory Provider Bulletin offers specific information regarding this requirement. For current application fee information, please see the Resources Section of the Medi-Cal Provider Enrollment Division page.
Kev lees paub thiab Medicare Certification
Ua ntej thov rau Medi-Cal, koj yuav tsum tau txais kev pom zoo rau Medicare Certification rau koj lub chaw phais mob / tsev kho mob. Cov chaw kho mob phais yuav nrhiav tau Medicare cov ntaub ntawv pov thawj los ntawm Lub Chaw rau Medicare thiab Medicaid Services (CMS) cov koom haum pom zoo lees paub raws li teev nyob rau hauv Pawg Kws Kho Mob ntawm California Lub Vev Xaib.
Cov ntaub ntawv xav tau
Tom ntej no, sau cov ntaub ntawv xav tau teev hauv qab no, raws li qhov siv tau, txhawm rau upload lawv rau hauv PAVE thaum koj ua tiav koj daim ntawv thov PAVE. Thov xyuas kom meej tias cov ntaub ntawv uas tau xa tuaj nyeem tau yooj yim.
1.Kev pom zoo Medicare Certification.
2. Daim Ntawv Tso Cai Tsav Tsheb lossis daim npav pov thawj uas lub xeev muab (muab tso rau hauv 50 Tebchaws Meskas lossis Lub Nroog Columbia) ntawm tus neeg muab kev pabcuam, lossis tus neeg kos npe rau daim ntawv thov uas muaj cai los khi tus neeg thov lossis tus neeg muab kev pabcuam raws li txoj cai. Cov kos npe yuav tsum yog tus neeg muab kev pab, tshwj tsis yog tias tus neeg muab kev pab yog ib lub koom haum. Yog tias tus neeg muab kev pabcuam yog ib lub koom haum thiab daim ntawv thov yuav raug kos npe los ntawm lwm tus neeg uas tsis yog tus neeg muab kev pabcuam, thov xa ib daim qauv ntawm ntu ntawm cov cai ntawm lub koom haum uas qhia txog lub hwj chim ntawm tus neeg kos npe los khi lub koom haum raws li txoj cai.
3.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 the application 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 visit IRS or call them at (800) 829-4933.
4. 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.”
5. 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 the application, 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, click on the “California’s Counties” link, and select “County Web Sites.” on the “California’s Counties” link, and select “County Web Sites.”
6.Seller’s Permit issued by the California State Board of Equalization, if applicable. Note: The business name and business address of the applicant or provider on the application must match the business name and business address on the seller’s permit. For further information, visit the Board of Equalization or call them at (916) 445-6362.
7. Fully executed Partnership Agreement, if your business is a partnership. Processing delays may be avoided by indicating whether the entity is a General Partnership or Limited Partnership and also submitting the following:
- Rau Kev Koom Tes Sib Koom Tes, ib daim ntawv teev npe ntawm txhua tus neeg koom tes nrog feem pua ntawm cov tswv cuab lossis tswj kev txaus siab rau txhua tus; los yog
- Rau Kev Koom Tes Ua Lag Luam Limited, 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 cov paj laum 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.
8. Yog tias koj lub lag luam yog ib lub koom haum, kev ncua sijhawm ua tiav yuav raug zam los ntawm kev muab daim ntawv theej ntawm Cov Cai ntawm Kev Koom Tes los ntawm Tus Tuav Ntaub Ntawv ntawm Lub Xeev, thiab daim ntawv teev cov thawj coj thiab cov tub ceev xwm lub npe thiab lub npe, nrog rau feem pua ntawm kev muaj thiab kev tswj hwm rau txhua tus. Yog xav paub ntxiv txog koj lub koom haum, thov mus saib Secretary of State California Business Portal thiab nias rau ntawm qhov txuas "California Business Search" lossis lwm qhov txuas uas tsim nyog.
9. Daim Ntawv Pov Thawj Txog Kev Pov Hwm Lub Luag Haujlwm Lag Luam (kev pov hwm rau kev lag luam, kev lav phib xaub dav dav, lossis kev lav phib xaub rau txhua qhov chaw ua haujlwm, lossis kev pov hwm chaw ua haujlwm) uas muaj nqi tsawg kawg yog $100,000 rau ib daim ntawv thov thiab tag nrho tsawg kawg yog $300,000 txhua xyoo. Daim ntawv pov thawj lees txais tau yog pov thawj tias koj muaj kev pov hwm tus kheej, lossis daim ntawv pov thawj pov hwm lossis daim ntawv tshaj tawm uas lub tuam txhab pov hwm muab uas muaj lub npe ntawm lub tuam txhab pov hwm, lub npe thiab chaw nyob ua lag luam ntawm tus neeg pov hwm, hnub pib siv, thiab cov kev txwv ntawm kev pov hwm. Lus Cim: Lub npe thiab chaw nyob ua lag luam, suav nrog tus lej chav tsev yog tias siv tau, ntawm tus neeg thov lossis tus neeg muab kev pab hauv daim ntawv thov yuav tsum phim lub npe thiab chaw nyob ntawm tus neeg pov hwm uas nyob rau ntawm daim ntawv pov hwm lossis daim ntawv tshaj tawm.
10.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 Clinical Laboratory License, must also show on the verification of the professional liability insurance.
11.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.
12.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.
13.Lub Luag Haujlwm Tom Qab Nrog Daim Ntawv Cog Lus Ua Ke Thiab Daim Ntawv Cog Lus Ua Ke (DHCS 6217), yog tias siv tau.