ライセンスクリニックの申請情報の免除
Exempt from Licensure Clinics are required to submit their individual and/or group applications via PAVE (Provider Application and Validation for Enrollment).
PAVEの申請書と一緒に、ビジネスのライセンス免除ステータスを説明する健康安全コードセクションを記載した手紙をアップロードする必要があります。すべての機器の登録番号と、該当する場合は放射線保健部門への登録証明をリストアップする必要があります。請求する予定のすべての診断サービスとCPTコードをリストする必要があります。サービスの技術コンポーネントを提供する技術者の名前(該当する場合)と、サービスの専門コンポーネントを提供する医師の名前をリストする必要があります。
申請料
Effective January 1, 2013, applicants requesting enrollment as a(n) Exempt from Licensure 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 455.460 Regulatory 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.
登録証明書とライセンス
Prior to applying to Medi-Cal, first check the Radiologic Health Branch (RHB) site, click on “Programs”, then “Radiologic Health Branch” and ensure you meet all the certification, registration and permit requirements as applicable to your clinic. Also, check with the Medical Board of Californiato ensure you meet all the licensing requirements. If applicable, also check with the California Department of Public Health, Lab Field Services Branch at (510) 620-3800 to ensure you meet all of the licensing requirements.
- RHB Radiation Machine Registration and/or Mammography Machine Certification; California Radiology Supervisor Operato Permit(s), Radiologic Technologist Certificate(s)/License(s) and/or X-Ray Technologist Permit(s) and/or Mammographic Radiologic Technologist Certificate(s), as applicable; current radioactive material license issued by DPH, Radiological Health Branch, as applicable; current FDA certified mammography facility certificate, as applicable; current California Medical License for supervising physician(s). All other medical certificates and registrations as required according to the type of equipment being used.
- Driver’s License or state-issued identification card (issued within the 50 United States or the District of Columbia) of the provider, or person signing the application who has the authority to legally bind the applicant or provider. The signature must be that of the provider, unless the provider is a corporation. If the provider is a corporation and the application is going to be signed by a person other than the provider, please submit a copy of the section of the corporation’s bylaws that identifies the signing person’s authority to legally bind the corporation.
- Driver’s License or state-issued identification card (issued within the 50 United States or the District of Columbia) of the provider, or person signing the application who has the authority to legally bind the applicant or provider. The signature must be that of the provider, unless the provider is a corporation. If the provider is a corporation and the application is going to be signed by a person other than the provider, please submit a copy of the section of the corporation’s bylaws that identifies the signing person’s authority to legally bind the corporation.
- 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 check with the IRS or call them at (800) 829-4933.
- 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 and click on the “California’s Counties” link, and select “County Web Sites.”
- 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 and select the “California’s Counties” link, then select “County Web Sites.”
- 臨床検査改善修正(CLIA)証明書 (すべてのページ)、検査サービスが提供されている場合に実施される検査のレベルに適しています。 詳細については、 メディケアおよびメディケイドサービスセンターをご覧ください。
- 注意:申請書に記載されている申請者またはプロバイダーの名前と勤務先住所、CLIA証明書、および州臨床検査室のライセンス/登録は正確に一致する必要があります。
- State Clinical Laboratory License/Registration, or verification of exemption from licensure/registration, if laboratory services are provided. Call the Laboratory Field Services office at (510) 620-3800 to determine what specific forms you are required to submit, and then download these forms. Pease Note: The name and business address of the applicant or provider on the application, the CLIA Certificate, and the State Clinical Laboratory License/Registration (or exemption) must exactly match.
- Fully executed Partnership Agreement, if your business is a partnership. 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. Processing delays may be avoided by indicating whether the entity is a General Partnership or Limited Partnership and also submitting the following:
- ジェネラル・パートナーシップの場合、すべてのパートナーのリストと、それぞれの所有権または支配権の割合。又は
- リミテッド・パートナーシップの場合、ゼネラル・パートナーを特定する情報、および各パートナーの所有権または支配権の割合を持つすべてのパートナーのリスト。
- If your business is a corporation, processing delays may be avoided by attaching a copy of the filed Articles of Incorporation from the California Secretary of State (or a Statement of Domestic Stock Corporation if your corporation is based outside of California), 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.
- Certificate of Commercial Liability Insurance (business, general, or comprehensive liability, or office premises insurance) in an amount of not less than $100,000 per claim and a minimum annual aggregate of $300,000. 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, effective dates, and limits of coverage. Note: The name and business address, including suite number if applicable, of the applicant or provider on the application must exactly match the insured’s name and address on the certificate of insurance or declaration sheet.
- Certificate of Professional Liability Insurance in an amount of not less than $100,000 per claim and a minimum annual aggregate of $300,000 for each licensed individual listed in the application package. 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(s), as appears on the licensed professional(s) license(s) must also show on the verification of the professional liability insurance.
- 労働者災害補償保険の証明書 は、あなたのビジネスに1人以上の従業員がいる場合、カリフォルニア州法で義務付けられています。 許容される検証は、自家保険に加入していることの証拠、または保険会社が発行した保険証書または保険会社が発行した申告書のいずれかで、保険会社の名前、被保険者の名前と事業所の住所、および発効日が含まれています。 労災保険が不要な場合は、説明が必要です。 注:申請者または提供者の名前と勤務先の住所は、保険証書に記載されている被保険者の名前と住所と完全に一致する必要があります。
- 連帯責任契約( DHCS 6217) による後継者責任(該当する場合)。
舗装ポータル
PAVEポータルに進みます。
Exempt from Licensure Clinic status change to FQHC:
If you are an exempt from licensure clinic that has changed your status to a Federally Qualified Health Center (FQHC) you must report a Change of Ownership and a
Change of Address using a Medi-Cal paper application. Please submit the following forms and all required documentation:
- Medi-Calプロバイダーアプリケーション (DHCS 6204)
- Medi-Calプロバイダー開示声明(DHCS 6207)
- Medi-Calプロバイダー契約 (DHCS-6208)