Clinic-Based Certified Nurse Midwife Application Information
This enrollment type is only for individual certified nurse midwives who provide primary care services exclusively at Medi-Cal enrolled, licensed primary care clinic(s), have no other established place of business (i.e. a medical office) where they provide services and who need to bill for inpatient maternity services provided to beneficiaries in a general acute care hospital. Groups are not eligible for this type of enrollment.
Pursuant to the regulatory Provider Bulletin published in June 2009, effective July 15, 2009, DHCS has established procedures for the enrollment of certified nurse midwives who are solely employed by or provide services pursuant to a contract with licensed primary care clinics, and who do not have any active Medi-Cal provider number issued to them individually to bill for clinical services to Medi-Cal beneficiaries at another location and as such, use the licensed primary care clinic as their established place of business. This type of enrollment allows the certified nurse midwife to bill for inpatient services only and not for services provided at the Licensed Primary Care Clinic. In order to determine whether or not you qualify for this type of enrollment, please read the detailed Provider Bulletin:
"Requirements and Procedures for 'Clinic-Based Certified Nurse Midwife' Enrollment".
Next, gather the required documents listed below, as applicable, in order to upload them into PAVE as you complete your PAVE application. Please ensure the uploaded documents are legible.
Current California Nursing License and
Current Nurse Midwife Certification. Please also include your DEA Registration Certificate and/or Nurse Midwife Furnishing Number, if applicable.
Driver’s License or state-issued identification card (issued within the 50 United States or the District of Columbia) of the applicant who signs application. The signature must be that of the certified nurse midwife applicant.
Federal Employer Identification Number (FEIN) or Individual Taxpayer Identification Number (ITIN) verification of the nurse midwife applicant,
only 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 the
IRS or call them at (800) 829-4933.
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 Medical License, must also show on the verification of the professional liability insurance.
If you are incorporated, 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.
Copy of your Fictitious Business Name Statement, only if applicable.
Proceed to the