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

• Aplikasyon para sa Tagapagbigay ng Serbisyo ng Medi-Cal, DHCS 6204 (hindi kinakailangan ang notarisasyon)
• 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.