ຂໍ້ມູນການສະໝັກພະຍາບານຜະດຸງຄັນ
ພະຍາບານຕໍາແຍແມ່ນຈໍາເປັນທີ່ຈະສົ່ງຄໍາຮ້ອງສະຫມັກສ່ວນບຸກຄົນແລະ / ຫຼືກຸ່ມຂອງເຂົາເຈົ້າໂດຍຜ່ານ PAVE (ຄໍາຮ້ອງສະຫມັກຂອງຜູ້ໃຫ້ບໍລິການແລະການກວດສອບສໍາລັບການລົງທະບຽນ). ຖ້າທ່ານກໍາລັງຍື່ນຄໍາຮ້ອງຂໍເປັນກຸ່ມ, ກະລຸນາໃຫ້ແນ່ໃຈວ່າທ່ານສົ່ງຄໍາຮ້ອງຂໍການສະແດງຜົນຢ່າງຫນ້ອຍສອງຢ່າງໃນ PAVE ເພື່ອສ້າງກຸ່ມຂອງທ່ານ.
ຖ້າທ່ານກໍາລັງລົງທະບຽນເປັນຜູ້ໃຫ້ບໍລິການ 'ຢືນຢູ່ຄົນດຽວ' ຫຼືເປັນ ‘clinic-based certified nurse midwife provider’
, ທ່ານຍັງຕ້ອງສົ່ງຄໍາຮ້ອງສະຫມັກຂອງທ່ານໂດຍຜ່ານ PAVE.
In accordance with Welfare and Institutions (W&I) Code Section 14043.75(b), requirements for certified nurse midwife providers who apply for enrollment in the Medi-Cal program have been updated. For more information, please see the regulatory provider bulletin titled, “Updated Place of Business Enrollment Requirements and Procedures for Licensed Midwives and Certified Nurse Midwives” and the Questions and Answers document from the Stakeholder Hearing held on August 1, 2024. Additionally, please see instructions regarding how to submit an application on PAVE based on your entity type:
- ຄໍາຮ້ອງສະຫມັກຜູ້ໃຫ້ບໍລິການຜະດຸງຄັນພະຍາບານ
- ຄໍາຮ້ອງສະຫມັກຜູ້ໃຫ້ບໍລິການການເອີ້ນເກັບເງິນສ່ວນບຸກຄົນຂອງພະຍາບານຜະດຸງຄັນ
- ຄໍາຮ້ອງສະຫມັກຜູ້ສະຫນອງການເອີ້ນເກັບເງິນຂອງກຸ່ມພະຍາບານຜະດຸງຄັນ
ໃບອະນຸຍາດ
ກ່ອນທີ່ຈະສະໝັກກັບ Medi-Cal, ທຳອິດໃຫ້ກວດເບິ່ງກັບ ຄະນະພະຍາບານທີ່ລົງທະບຽນຢູ່ໃນລັດຄາລິຟໍເນຍ ເພື່ອຮັບປະກັນວ່າເຈົ້າຕອບສະໜອງໄດ້ທຸກເງື່ອນໄຂການອອກໃບອະນຸຍາດ.
ເອກະສານທີ່ຕ້ອງການ
ຕໍ່ໄປ, ລວບລວມເອກະສານທີ່ກໍານົດໄວ້ຂ້າງລຸ່ມນີ້, ຕາມທີ່ສາມາດນໍາໃຊ້ໄດ້, ເພື່ອອັບໂຫລດພວກມັນເຂົ້າໄປໃນ PAVE ໃນຂະນະທີ່ທ່ານເຮັດສໍາເລັດຄໍາຮ້ອງສະຫມັກ PAVE ຂອງທ່ານ. ກະລຸນາກວດສອບວ່າເອກະສານທີ່ອັບໂຫລດນັ້ນຖືກຕ້ອງແລ້ວ.
1. ໃບອະນຸຍາດພະຍາບານທີ່ລົງທະບຽນ California ແລະ California Nurse-Midwife Certificate; California Nurse-Midwife Furnishing Certificate ຖ້າອຸປະກອນຕົກແຕ່ງຢາ ແລະອຸປະກອນຕາມລະຫັດ B&P ມາດຕາ 2746.51 ແລະການລົງທະບຽນ DEA ຖ້າທ່ານໃຫ້ສານຄວບຄຸມ.
2. ໃບຂັບຂີ່ ຫຼືບັດປະຈຳຕົວທີ່ອອກໃຫ້ໂດຍລັດ (ອອກໃຫ້ພາຍໃນ 50 ສະຫະລັດ ຫຼື District of Columbia) ສຳລັບຜູ້ສະໝັກ.
3. ໃບຢັ້ງຢືນການປະກັນໄພຄວາມຮັບຜິດຊອບດ້ານວິຊາຊີບ ໃນຈໍານວນບໍ່ຕໍ່າກວ່າ 100,000 ໂດລາຕໍ່ການຮຽກຮ້ອງ ແລະລວມຍອດປະຈໍາປີຂັ້ນຕໍ່າ $300,000. ການກວດສອບທີ່ຍອມຮັບໄດ້ແມ່ນໃບຢັ້ງຢືນການປະກັນໄພຫຼືໃບປະກາດທີ່ອອກໂດຍບໍລິສັດປະກັນໄພທີ່ມີຊື່ຂອງບໍລິສັດປະກັນໄພ, ຊື່ຂອງຜູ້ປະກັນໄພ, ວັນທີທີ່ມີຜົນບັງຄັບໃຊ້, ແລະຂອບເຂດຈໍາກັດຂອງການຄຸ້ມຄອງ. ໝາຍເຫດ: ຊື່ຜູ້ໃຫ້ບໍລິການ, ດັ່ງທີ່ປາກົດຢູ່ໃນໃບທະບຽນພະຍາບານທີ່ລົງທະບຽນຢູ່ໃນລັດຄາລິຟໍເນຍ ແລະໃບຢັ້ງຢືນການຜະດຸງຄັນຂອງພະຍາບານ, ຕ້ອງສະແດງຢູ່ໃນການຢັ້ງຢືນການປະກັນໄພຄວາມຮັບຜິດຊອບດ້ານວິຊາຊີບ.
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’: ໃບຢັ້ງຢືນການປະກັນໄພຄວາມຮັບຜິດຊອບທາງການຄ້າ (ທຸລະກິດ, ທົ່ວໄປ, ຫຼືຄວາມຮັບຜິດຊອບທີ່ສົມບູນແບບ, ຫຼືການປະກັນໄພສະຖານທີ່ຫ້ອງການ) ໃນຈໍານວນບໍ່ຫນ້ອຍກວ່າ $ 100,000 ຕໍ່ການຮຽກຮ້ອງແລະຈໍານວນຕໍາ່ສຸດທີ່ປະຈໍາປີຂອງ $ 300,000. ການກວດສອບທີ່ຍອມຮັບໄດ້ແມ່ນຫຼັກຖານຂອງການປະກັນໄພຕົນເອງ, ຫຼືໃບຢັ້ງຢືນການປະກັນໄພຫຼືໃບປະກາດທີ່ອອກໂດຍບໍລິສັດປະກັນໄພທີ່ມີຊື່ຂອງບໍລິສັດປະກັນໄພ, ຊື່ແລະທີ່ຢູ່ທຸລະກິດຂອງຜູ້ປະກັນໄພ, ວັນທີທີ່ມີຜົນບັງຄັບໃຊ້, ແລະຂອບເຂດຈໍາກັດຂອງການຄຸ້ມຄອງ. ໝາຍເຫດ: ຊື່ ແລະທີ່ຢູ່ທຸລະກິດ, ລວມທັງໝາຍເລກຊຸດຖ້າມີ, ຂອງຜູ້ສະໝັກ ຫຼືຜູ້ໃຫ້ບໍລິການໃນໃບສະໝັກຕ້ອງກົງກັບຊື່ ແລະທີ່ຢູ່ຂອງຜູ້ປະກັນຕົນໃນໃບຮັບຮອງປະກັນໄພ ຫຼືໃບປະກາດ.
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 enrollmen t’: If your business is a corporation, processing delays may be avoided by attaching a copy of the filed Articles of Incorporation from the Secretary of State, 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.
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) ສໍາລັບຫຸ້ນສ່ວນທົ່ວໄປ, ບັນຊີລາຍຊື່ຂອງຄູ່ຮ່ວມງານທັງຫມົດທີ່ມີອັດຕາສ່ວນການເປັນເຈົ້າຂອງຫຼືການຄວບຄຸມຄວາມສົນໃຈສໍາລັບແຕ່ລະຄົນ; ຫຼື
b) ສໍາລັບຫຸ້ນສ່ວນຈໍາກັດ, ຂໍ້ມູນການກໍານົດຄູ່ຮ່ວມງານທົ່ວໄປ, ແລະບັນຊີລາຍຊື່ຂອງຄູ່ຮ່ວມງານທັງຫມົດທີ່ມີອັດຕາສ່ວນການເປັນເຈົ້າຂອງຫຼືການຄວບຄຸມຄວາມສົນໃຈສໍາລັບແຕ່ລະຄົນ.
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.
12. For ‘individual stand alone enrollment’: Successor Liability with Joint and Several Liability Agreement (DHCS 6217), if applicable.