면허 클리닉 신청 면제 정보
Exempt from Licensure Clinics are required to submit their individual and/or group applications via PAVE (Provider Application and Validation for Enrollment).
사업체의 면허 면제 상태를 설명하는 보건 및 안전 코드 섹션이 기재된 서신을 PAVE에 신청서와 함께 업로드해야 하며, 모든 장비 등록 번호와 방사선 보건 지부에 등록한 증거(해당되는 경우)를 기재하고, 청구하려는 모든 진단 서비스와 CPT 코드를 기재하고, 서비스의 기술적 구성 요소를 제공하는 기술자의 이름(해당하는 경우)과 서비스의 전문적 구성 요소를 제공하는 의사의 이름을 기재해야 합니다.
신청 수수료
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.
등록 및 라이선스 인증서
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.”
- 실험실 서비스가 제공되는 경우 수행된 테스트 수준에 적합한 CLIA(임상 실험실 개선 개정안) 인증서 (모든 페이지). 자세한 내용은 Medicare 및 메디케이드 서비스 센터를 참조하세요.
- 참고: 신청서에 기재된 신청자 또는 제공자의 이름과 사업장 주소, CLIA 인증서, 주 임상실험실 면허/등록증이 정확히 일치해야 합니다.
- 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:
- 합자회사의 경우, 각 파트너의 소유권 또는 지배지분 비율과 함께 모든 파트너의 목록 또는
- 합자회사의 경우, 무한책임사원을 식별하는 정보와 각 파트너의 소유권 또는 지배지분 비율과 함께 모든 파트너의 목록입니다.
- 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.
- 캘리포니아주 법에 따라 비즈니스에 직원이 한 명 이상 있는 경우 산재보험 증명서가 필요합니다. 허용되는 증빙 서류는 자체 보험에 가입했음을 증명하는 서류 또는 보험회사 이름, 피보험자의 이름 및 사업장 주소, 유효 날짜가 포함된 보험회사에서 발행한 보험증권 또는 신고서입니다. 산재 보험이 필요하지 않은 경우에는 반드시 설명을 제공해야 합니다. 참고: 신청자 또는 제공자의 이름과 사업장 주소는 보험증권에 기재된 피보험자의 이름과 주소와 정확히 일치해야 합니다.
- 해당되는 경우 공동 및 다중 책임 계약 (DHCS 6217)을 통한 승계인 책임 .
PAVE 포털
PAVE 포털로 이동합니다.
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 제공자 신청서 (DHCS 6204)
- Medi-Cal 제공자 공개 내역서 (DHCS 6207)
- Medi-Cal 의료 서비스 제공자 계약 (DHCS-6208)