Sentro ng Surgery na Pag-aari ng Doktor o Surgical Clinic Application Information
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.
Ang mga Sentro ng Surgery na Pagmamay-ari ng Doktor at Mga Provider ng Surgical Clinic ay kinakailangang isumite ang kanilang mga indibidwal at/o grupong aplikasyon sa pamamagitan ng PAVE (Aplikasyon ng Provider at Pagpapatunay para sa Pagpapatala).
Bayad sa Application
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.
Akreditasyon at Sertipikasyon ng Medicare
Bago mag-apply sa Medi-Cal, dapat ay nakakuha ka ng pag-apruba para sa Medicare Certification para sa iyong surgery center/klinika. Ang mga surgical clinic ay maaaring humingi ng Medicare certification status sa pamamagitan ng Centers for Medicare and Medicaid Services (CMS) aprubadong mga organisasyon ng akreditasyon gaya ng nakalista sa Medical Board of California Website.
Mga Kinakailangang Dokumento
Sunod, tipunin ang mga kinakailangang dokumentong nakalista sa ibaba, kung naaangkop, upang mai-upload ang mga ito sa PAVE habang kinukumpleto mo ang iyong aplikasyon sa PAVE. Pakitiyak na ang mga na-upload na dokumento ay madaling mabasa.
1.Pag-apruba ng Sertipikasyon ng Medicare.
2. Lisensya sa Pagmamaneho o identification card na inisyu ng estado (na inisyu sa loob ng 50 Estados Unidos o Distrito ng Columbia) ng tagapagbigay ng serbisyo, o taong pumirma sa aplikasyon na may awtoridad na legal na ipasailalim ang aplikante o tagapagbigay ng serbisyo. Ang lagda ay dapat ng tagapagbigay ng serbisyo, maliban na lang kung ito ay isang korporasyon. Kung ang tagapagbigay ng serbisyo ay isang korporasyon at ang aplikasyon ay pipirmahan ng ibang tao bukod sa tagapagbigay ng serbisyo, mangyaring magsumite ng kopya ng seksyon ng mga tuntunin ng korporasyon na tumutukoy sa awtoridad ng taong lumagda na legal na ipasailalim ang korporasyon.
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:
- 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.
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. Kung ang iyong negosyo ay isang korporasyon, maaaring maiwasan ang mga pagkaantala sa pagproseso sa pamamagitan ng paglakip ng isang kopya ng inihaing Artikulo ng Pagsasama mula sa Kalihim ng Estado, at isang listahan ng mga pangalan at titulo ng mga direktor at opisyal, kasama ang porsyento ng pagmamay-ari at kontrol na interes para sa bawat isa. Para beripikahin o baguhin ang pangalan at/o katayuan ng iyong korporasyon o para sa karagdagang impormasyon, pakibisita ang California Business Portal ng Kalihim ng Estado at i-click ang link na “Paghahanap ng Negosyo sa California” o iba pang naaangkop na link.
9. Sertipiko ng Seguro sa Pananagutan sa Komersyal (seguro sa negosyo, pangkalahatan, o komprehensibong pananagutan, o lugar ng opisina) na may halagang hindi bababa sa $100,000 bawat claim at may minimum na taunang kabuuang $300,000. Ang katanggap-tanggap na beripikasyon ay alinman sa ebidensya ng pagiging self-insured, o isang sertipiko ng seguro o deklarasyon na inisyu ng kompanya ng seguro na naglalaman ng pangalan ng kompanya ng seguro, ang pangalan at address ng negosyo ng nakaseguro, mga petsa ng pagiging epektibo, at mga limitasyon ng saklaw. Paalala: Ang pangalan at address ng negosyo, kasama ang numero ng suite kung naaangkop, ng aplikante o provider sa aplikasyon ay dapat na eksaktong tumutugma sa pangalan at address ng nakaseguro sa sertipiko ng seguro o deklarasyon.
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.Pananagutang Kahalili na may Kasunduan sa Pananagutan na Magkasama at Magkahiwalay (DHCS 6217), kung naaangkop.