Exempt mula sa Licensure Clinic Application Information
Exempt from Licensure Clinics are required to submit their individual and/or group applications via PAVE (Provider Application and Validation for Enrollment).
Dapat mag-upload ng sulat kasama ng iyong aplikasyon sa PAVE na nagsasaad ng Health and Safety Code Section na naglalarawan ng Exempt ng iyong negosyo sa status ng Licensure; dapat ilista ang lahat ng mga numero ng pagpaparehistro ng kagamitan at patunay ng pagpaparehistro sa Radiological Health Branch kung naaangkop; dapat ilista ang lahat ng mga serbisyong diagnostic at ang mga CPT Code na nilayon mong singilin; dapat ilista ang mga pangalan ng mga technician na nagbibigay ng teknikal na bahagi ng mga serbisyo (kung naaangkop) at ang mga pangalan ng mga doktor na nagbibigay ng propesyonal na bahagi ng mga serbisyo.
Bayad sa Application
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.
Sertipiko ng Pagpaparehistro at Mga Lisensya
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.”
- Sertipiko ng Clinical Laboratory Improvement Amendment (CLIA)(lahat ng mga pahina), na angkop para sa antas ng pagsubok na isinagawa, kung ang mga serbisyo sa laboratoryo ay ibinigay. Para sa karagdagang impormasyon, bisitahin ang Centers for Medicare and Medicaid Services.
- Pakitandaan: Ang pangalan at address ng negosyo ng aplikante o provider sa aplikasyon, ang CLIA Certificate, at ang State Clinical Laboratory License/Registration ay dapat na eksaktong magkatugma.
- 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:
- Para sa isang Pangkalahatang Pakikipagsosyo, isang listahan ng lahat ng mga kasosyo na may porsyento ng pagmamay-ari o kontrol na interes para sa bawat isa; o
- Para sa Limited Partnership, impormasyong nagpapakilala sa General Partner, at isang listahan ng lahat ng partner na may porsyento ng pagmamay-ari o kontrol na interes para sa bawat isa.
- 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.
- Ang Certificate of Workers' Compensation Insurance ay kinakailangan ng batas ng California, kung ang iyong negosyo ay may isa o higit pang empleyado. Ang katanggap-tanggap na pag-verify ay alinman sa katibayan ng pagiging self-insured, o isang sertipiko ng insurance o declaration sheet na inisyu ng kumpanya ng insurance na naglalaman ng pangalan ng kompanya ng insurance, ang pangalan at address ng negosyo ng nakaseguro, at mga petsa ng bisa. Kung walang seguro sa Kompensasyon ng mga Manggagawa ang kailangan, kailangang magbigay ng paliwanag. Tandaan: Ang pangalan at address ng negosyo ng aplikante o provider ay dapat na eksaktong tumugma sa pangalan at address ng nakaseguro sa sertipiko ng insurance.
- Successor Liability with Joint and Several Liability Agreement (DHCS 6217), kung naaangkop.
PAVE Portal
Magpatuloy sa PAVE portal.
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 Provider Application (DHCS 6204)
- Pahayag ng Pagbubunyag ng Tagabigay ng Medi-Cal (DHCS 6207)
- Kasunduan sa Provider ng Medi-Cal (DHCS-6208)