Daim Ntawv Thov Kev Pabcuam Saib Xyuas Kev Pabcuam (CCA) yuav tsum muaj
- Tus nqi thov : Cashier's Check nyob rau hauv tus nqi ntawm $730.00 them rau lub Department of Health Care Services
- Daim ntawv thov Medi-Cal muab kev pab, DHCS 6204 (yuav tsum tau notarized)
- Medi-Cal Disclosure Statement, DHCS 6207 (yuav tsum tau notarized)
- Medi-Cal Muab Kev Pom Zoo, DHCS 6208 (yuav tsum tau notarized)
- Kev lag luam email cuam tshuam rau CCA
- Pov thawj ntawm National Provider Identifier (NPI): NPE NPI Registry Kev lees paub
- 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
- 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 Kev lees paub
- 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 tias koj muaj lus nug txog daim ntawv thov, c tag nrho (916) 552-9105, xaiv 5, ces xaiv 2. Cov lus nug email tuaj yeem xa mus rau WaiveProEnroll@dhcs.ca.gov. 