Tahanan Mga Serbisyo Mga Alternatibo sa Pangmatagalang Pangangalaga (Mga Opsyon sa Serbisyo sa Bahay at Komunidad) Mga Kinakailangan sa Aplikasyon para sa Indibidwal na Tagapagbigay ng Nars (INP)

Mga Kinakailangan sa Application ng Indibidwal na Nurse Provider (INP).

Medi-Cal Provider Application, DHCS 6204 (notarization not required)
Medi-Cal Disclosure Statement, DHCS 6207 (notarization not required)
Medi-Cal Provider Agreement, DHCS 6208 (notarization not required)
Proof of National Provider Identifier (NPI): NPPES NPI Registry Confirmation
Printout ng Lisensya ng Department of Consumer Affairs (DCA).
Wastong ID na Inisyu ng Estado o Lisensya sa Pagmamaneho
Wastong Sertipikasyon ng Basic Life Support (BLS).
Propesyonal na Pananagutan (Malpractice) Insurance Coverage
Resume. Describe training and experience providing nursing care to patients.

For LVN applicants only: Provide the name of the RN who will be providing ongoing supervision, along with the RN’s license number.For RN applicants only: Include a breakdown of hours worked for each position listed from the last five years, e.g., 40 hours per week x 52 weeks per year = total number of hours worked per year.

Isumite ang kumpletong pakete ng aplikasyon sa:

Department of Health Care Services

Pinagsamang Sistema ng Dibisyon ng Pangangalaga

Yunit ng Enrollment ng Provider

1501 Capitol Avenue, MS 4502

PO Kahon 997437

Sacramento, CA 95899-7437

PAKITANDAAN: IPADALA ANG PACKAGE SA PROVIDER ENROLLMENT UNIT

HUWAG MAGPADALA NG ANUMANG DOKUMENTO SA PROVIDER ENROLLMENT DIVISION

If you have questions regarding the application requirements, call (916) 552-9105, option 5, then option 2. Email inquiries can be sent to WaiveProEnroll@dhcs.ca.gov.