ナースプラクティショナー 応募情報
ナースプラクティショナー PAVE(Provider Application and Validation for Enrollment)を介して個人および/またはグループの申請書を提出する必要があります。 グループで応募する場合は、PAVEで少なくとも2つのレンダリング応募も提出してください。
ライセンス
Medi-Calに申し込む前に、まずカリフォルニア州登録看護委員会 に確認して、すべてのライセンス要件を満たしていることを確認してください。
必要書類
次に、必要に応じて以下に示す必要書類を収集し、PAVEアプリケーションの完了時にPAVEにアップロードします。 アップロードした書類が判読可能であることを確認してください。
1.カリフォルニア州登録看護師免許およびカリフォルニア州 登録看護委員会によって認められた全国または州の組織からのナースプラクティショナーの証明書、および専門分野トレーニングの分野を明記。
2.申請者の運転免許証または州発行の身分証明書 (米国50州またはコロンビア特別区内で発行されたもの)。
3.請求ごとに100,000ドル以上、最低年間総額が300,000ドルの専門職賠償責任保険の証明書。許容される検証は、保険会社の名前、被保険者の名前、発効日、および補償限度額が記載された保険会社が発行する保険証書または申告書です。 注:カリフォルニア州登録看護師免許およびナースプラクティショナー証明書に記載されているプロバイダーの名前は、専門職賠償責任保険の検証にも表示する必要があります。
4. For ‘individual stand alone enrollment’: Federal Employer Identification Number (FEIN) 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 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 the IRS or call them at (800) 829-4933.
5. For ‘individual stand alone enrollment’: 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.
6. For ‘individual stand alone enrollment’: 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 match the insured’s name and address on the certificate of insurance.
7. For ‘individual stand alone enrollment’: 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.
8. For ‘individual stand alone enrollment’: 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.”
9. For ‘individual stand alone enrollment’: 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 click on the “California’s Counties” link, and select “County Web Sites.”
10. For ‘individual stand alone enrollment’ : あなたのビジネスが法人である場合、国務長官から提出された定款のコピー、および取締役および役員の名前と役職のリスト、およびそれぞれの所有権と支配権の割合を添付することで、処理の遅延を回避できます。
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.
11. For ‘individual stand alone enrollment’: If your business is a partnership, a fully executed Partnership Agreement. Processing delays may be avoided by indicating whether the entity is a General Partnership or Limited Partnership and also submitting the following:
a) 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
b)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と、それぞれ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。
パートナーシップの名称および/またはステータスを確認または変更する場合、または詳細については、 カリフォルニア州国務長官ビジネスポータルにアクセスし、「カリフォルニアビジネスサーチ」リンクまたはその他の適切なリンクをクリックしてください。
12. For ‘individual stand alone enrollment’: Successor Liability with Joint and Several Liability Agreement (DHCS 6217), if applicable.