의사 소유의 수술 센터 또는 외과 클리닉 신청 정보
If your surgery center does not have any percentage of ownership by physicians, then you need to contact the California Department of Public Health’s Licensing and Certification Division for information regarding enrolling as a Medi-Cal provider, instead of enrolling through PED.
의사 소유의 수술 센터 및 수술 클리닉 제공업체는 PAVE(제공자 신청 및 등록 확인)를 통해 개인 및/또는 단체 신청서를 제출해야 합니다.
신청 수수료
Effective January 1, 2013, applicants requesting enrollment as a Physician-Owned Surgery Center or Surgical 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 455.460Regulatory 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.
인증 및 Medicare 인증
Medi-Cal 에 신청하기 전에 수술 센터/클리닉에 대한 Medicare 인증 승인을 받아야 합니다. 외과 클리닉은 캘리포니아주 의료위원회웹사이트에 나와 있는 인증 기관( ) 및 메디케이드 서비스(CMS) 승인 인증 기관을 통해 인증 상태를 확인할 수 있습니다.Medicare Medicare
필수 서류
다음으로, PAVE 신청서를 작성하면서 PAVE 시스템에 업로드할 아래 나열된 필수 서류를 해당되는 경우 준비하십시오. 업로드하신 문서가 읽기 쉬운지 확인해 주세요.
1.Medicare 인증 승인.
2. 서비스 제공자 또는 신청자나 서비스 제공자를 법적으로 구속할 권한이 있는 사람이 신청서에 서명할 때 소지한 운전면허증 또는 주정부 발행 신분증 (미국 50개 주 또는 컬럼비아 특별구 내에서 발급된 것). 제공자가 법인인 경우를 제외하고는 서명은 제공자의 서명이어야 합니다. 제공자가 법인이고 신청서에 제공자 본인이 아닌 다른 사람이 서명할 경우, 서명자가 법인을 법적으로 구속할 권한을 명시한 법인 정관 조항 사본을 제출해 주십시오.
3.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 visit IRS or call them at (800) 829-4933.
4. 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 Web site, click on the “California’s Counties” link, and select “County Web Sites.”
5. 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 Web site, click on the “California’s Counties” link, and select “County Web Sites.” on the “California’s Counties” link, and select “County Web Sites.”
6.Seller’s Permit issued by the California State Board of Equalization, if applicable. Note: The business name and business address of the applicant or provider on the application must match the business name and business address on the seller’s permit. For further information, visit the Board of Equalization or call them at (916) 445-6362.
7. Fully executed Partnership Agreement, if your business is a partnership. 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.
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.
8. 사업체가 법인인 경우, 주무 장관실에 제출된 정관 사본 과 이사 및 임원의 성명 및 직책 목록, 그리고 각 임원의 소유 지분 및 경영권 비율을 첨부하면 처리 지연을 방지할 수 있습니다. 법인명 및/또는 법인 상태를 확인하거나 변경하거나 추가 정보를 얻으려면 캘리포니아 주 국무장관 사업자 포털(California Secretary of State Business Portal)을 방문하여 "캘리포니아 사업자 검색(California Business Search)" 링크 또는 기타 적절한 링크를 클릭하십시오.
9. 건당 최소 10만 달러, 연간 최소 총액 30만 달러 이상의 상업 배상 책임 보험 증명서 (사업, 일반 또는 종합 배상 책임 보험 또는 사무실 건물 보험). 인정되는 증빙 자료는 자가 보험 가입 증명서 또는 보험 회사에서 발행한 보험 증명서나 보험 명세서로서, 보험 회사명, 피보험자의 이름과 사업장 주소, 유효 기간 및 보상 한도가 명시된 서류입니다. 참고: 신청서에 기재된 신청자 또는 제공자의 이름과 사업장 주소 (해당하는 경우 호실 번호 포함)는 보험 증명서 또는 보험 증권에 기재된 피보험자의 이름과 주소와 정확히 일치해야 합니다.
10.Certificate of Professional Liability Insurance in an amount of not less than $100,000 per claim and a minimum annual aggregate of $300,000. 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, as it appears on the California Clinical Laboratory License, must also show on the verification of the professional liability insurance.
11.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 exactly match the insured’s name and address on the certificate of insurance.
12.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.
13.해당되는 경우 , 연대책임 약정에 따른 승계책임(DHCS 6217 ).