Tsev Cov Kev Pabcuam Cov Kev Xaiv Rau Kev Saib Xyuas Mus Ntev (Kev Xaiv Kev Pabcuam Hauv Tsev thiab Hauv Zej Zog) Cov Kev Cai Rau Daim Ntawv Thov Kev Pab Cuam Tus Kws Saib Xyuas Neeg Mob (INP)​​ 

Ib Tus Neeg Saib Xyuas Neeg Mob (INP) Daim Ntawv Thov Kev Pab​​ 

  • Medi-Cal Provider Application, DHCS 6204 (notarization not required)​​ 
  • Medi-Cal Disclosure Statement, DHCS 6207 (notarization not required)​​ 
  • Medi-Cal Provider Agreement, DHCS 6208 (notarization not required)​​ 
  • Proof of National Provider Identifier (NPI): NPPES NPI Registry Confirmation​​ 
  • Department of Consumer Affairs (DCA) Licence Printout​​ 
  • Siv tau State-Issued ID lossis Driver's License​​ 
  • Siv tau Basic Life Support (BLS) Certification​​ 
  • Kev lav phib xaub (kev ua tsis raug cai) kev pov hwm kev pov hwm​​ 
  • Resume. Describe training and experience providing nursing care to patients.​​ 
    For LVN applicants only: Provide the name of the RN who will be providing ongoing supervision, along with the RN’s license number.For RN applicants only: Include a breakdown of hours worked for each position listed from the last five years, e.g., 40 hours per week x 52 weeks per year = total number of hours worked per year.​​ 

Xa daim ntawv thov ua tiav pob rau:​​ 

Department of Health Care Services​​ 

Integrated Systems of Care Division​​ 

Chaw Muab Npe Rau Npe​​ 

1501 Capitol Avenue, MS 4502​​ 

PO ib 997437​​ 

Sacramento, CA 95899-7437​​ 

THOV NCO NTSOOV: Xa pob khoom mus rau qhov chaw muab kev tso npe nkag​​  

TSIS TXAUS SIAB TXOJ CAI TXOJ CAI NTAWM TUS TSWV TSEV KAWM NTAWV​​ 

If you have questions regarding the application requirements, call (916) 552-9105, option 5, then option 2. Email inquiries can be sent to WaiveProEnroll@dhcs.ca.gov.​​