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
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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.