• Tus Nqi Thov: Daim Cheque ntawm Tus Neeg Sau Nyiaj uas yog $730.00 them rau Lub Chaw Haujlwm Saib Xyuas Kev Noj Qab Haus Huv​​ 
• Daim Ntawv Thov Kev Pab Cuam Medi-Cal, DHCS 6204 (yuav tsum tau muaj neeg ua pov thawj)​​ 
• Daim Ntawv Qhia Txog Kev Pom Zoo ntawm Medi-Cal, DHCS 6207 (yuav tsum tau muaj neeg ua pov thawj)​​ 
• Daim Ntawv Cog Lus Muab Kev Pabcuam Medi-Cal, DHCS 6208 (yuav tsum tau muaj neeg ua pov thawj)​​ 
• Kev lag luam email cuam tshuam rau RCFE/ARF​​ 
• Proof of National Provider Identifier (NPI): NPPES NPI Registry Confirmation​​ 
• Pov thawj ntawm Tsoom Fwv Teb Chaws Tus Neeg Them Se Tus Naj Npawb (TIN): IRS Tsab Ntawv SS-4, IRS Daim Ntawv 941, Daim Ntawv 8109-C, lossis Tsab Ntawv 147-C​​ 
• Daim ntawv tso cai ua lag luam hauv nroog lossis tsab ntawv zam​​ 
• Daim ntawv tso cai muab los ntawm Department of Social Services​​ 
• Lub Xeev Muab ID lossis Daim Ntawv Tso Cai Tsav Tsheb (nrog rau cov ntawv luam rau txhua tus neeg muaj npe nyob rau hauv daim ntawv Medi-Cal)​​ 
• Ua Lag Luam Raws Li (DBA) lossis Cov Lus Qhia Lub Npe Ua Lag Luam (yuav tsum tau tsuas yog tias kev lag luam ua haujlwm raws li lub npe txawv dua li lub npe lag luam uas twb muaj lawm)​​ 
• General Liability Insurance​​ 
• Nyiaj Pov Hwm Kev Ua Haujlwm​​ 
• Surety Bond lossis Exemption Letter​​ 
• Secretary of State Confirmation​​ 
• Cov khoom ntawm Incorporation los yog Cov Khoom ntawm Lub Koom Haum​​ 

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​​ 

Yog koj muaj lus nug txog cov cai ntawm daim ntawv thov, hu rau (916) 552-9105, xaiv 5, ces xaiv 2. Cov lus nug hauv email tuaj yeem xa mus rau WaiveProEnroll@dhcs.ca.gov.​​