Hospital -Based Physician Application Package Instructions
Eligibility: If you are an individual physician (Doctor of Medicine or Osteopathic Physician) and your medical practice is based in one or more general acute care hospitals, rural general acute care hospitals, or an acute psychiatric hospital; you do not have an adverse entry in the Healthcare Integrity and Protection Databank; and you hold a current, unrevoked, or unsuspended license as a physician and surgeon issued by the Medical Board of California or the Osteopathic Medical Board of California, you are eligible to enroll as a hospital-based physician. Your California license to practice medicine shall not have a revocation stayed, have been placed on probation, or be subject to any other limitation.
Pursuant to the regulatory Provider Bulletin published in the May 2008, you need to complete one Medi-Cal form, and attach a number of required documents, as verification of information you provide on the Medi-Cal form. All questions and blanks on the form must be completed. Also, legible and current copies of all required documents must be submitted in order for the application package to be considered complete. An incomplete application package will prolong your enrollment process because it will be returned to you for correction and/or completion. The Provider Enrollment staff can not make any changes to your documents.
Prior to applying to Medi-Cal, first check the Medical Board of California Web site at www.mbc.ca.gov to ensure you meet all the licensing requirements shown on their links, "Applicants", "Licensees" and "Laws & Regulations" or the Osteopathic Medical Board of California Web site at www.ombc.ca.gov to ensure you meet all the licensing requirements shown on their link, "Laws & Regulations."
Next, make legible copies of current documents that are required to be submitted with your Medi-Cal application form, as listed below.
1. Current California Medical License or Osteopathic Physician and Surgeons License of applicant or provider. Please include Anesthesia Permit, Conscious Sedation Permit and/or DEA Certificate, if applicable.
2. 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 forms who has the authority to legally bind the applicant or provider.
3. National Plan and Provider Enumeration System (NPPES) confirmation for each National Provider Identifier (NPI) you list in the application package. Acceptable NPI documentation is one of the following: 1) NPI notification letter from the NPPES, 2) NPI notification e-mail from NPPES, or 3) NPI notification letter or e-mail from the Electronic File Interchange Organization (EFIO). Note: The name and business address of the applicant or provider on all forms must exactly match the name and practice location on the NPPES or EFIO notification. For information on how to apply for an NPI or update your information in NPPES, visit the Medi-Cal Web site at www.medi-cal.ca.gov, and click on the "NPI" link, or go to https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart.
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4. 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 all forms 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 contact the IRS at (800) 829-4933 or www.irs.gov.
5. Clinical Laboratory Improvement Amendment (CLIA) Certificate (all pages), appropriate for the level of testing performed, if laboratory services are provided. For further information, visit the Centers for Medicare and Medicaid Services Web page at http://www.cms.hhs.gov/CLIA/downloads/HowObtainCLIACertificate.pdf.
Note: The name and business address of the applicant or provider on all forms, the CLIA Certificate, and the State Clinical Laboratory License/Registration must exactly match.
6. 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 from
Note: The name and business address of the applicant or provider on all forms, the CLIA Certificate, and the State Clinical Laboratory License/Registration (or exemption) must exactly match.
7. Fictitious Name Permit (FNP) issued by the Medical Board of California or the Osteopathic Medical Board of California, if using a fictitious name for your medical practice, as defined by the Board. Note: The business name of the applicant or provider on all forms, all local business licenses/permits, and the FNP must exactly match. For further information, visit the Medical Board Web site at www.mbc.ca.gov, and click on the "Licenses" tab, then the Fictitious Name Permit" link or visit the Osteopathic Medical Board Web site at www.ombc.ca.gov, click on the "Forms and Publications" tab, and then "Fictitious Name Permit."
8. 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:
a) For a General Partnership, a list of all partners with percent of ownership or control interest for each; or
b) For a Limited Partnership, information identifying the General Partner, and a list of all partners with percent of ownership or control interest for each.
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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 Web page at www.sos.ca.gov/business/business.htm, and click on the "California Business Search" link or other appropriate link.
9. 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 or status of your corporation, or for further information, please visit the Secretary of State California Business Portal Web page at www.sos.ca.gov/business/business.htm, and click on the "California Business Search" link or other appropriate link.
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 Medical License, must also show on the verification of the professional liability insurance.
11. Successor Liability with Joint and Several Liability Agreement (DHCS 6217), if applicable. For further information on using successor liability, visit the Medi-Cal Web site at www.medi-cal.ca.gov, and click on the "Provider Enrollment" link, then "Statutes, Regulations and Provider Bulletins, " and then select the Provider Bulletins entitled "Important Reminder: Providers Selling or Purchasing a Business" and "Requirements and Procedures for Successor Liability."
You may need to submit additional documents or complete a full Medi-Cal Disclosure Statement (DHCS 6207), depending upon answers to certain questions on the Disclosure Statement portion of the Hospital-Based Physician application. The document requirements are subject to change depending upon future changes in enrollment regulations and/or state law.
PROCEED TO THE APPLICATION FORM NEEDED
Medi-Cal Hospital-Based Physician Application/Disclosure Statement/Agreement (DHCS 9095)