合格

这种登记类型仅适用于在 Medi-Cal 登记的持牌初级保健诊所专门提供医疗服务、没有其他既定营业地点（即医疗办公室）提供服务并且需要为在综合急症护理医院或急性精神病医院环境中向受益人提供的住院服务开具账单的个人医生。 团体不符合此类招生资格。

Pursuant to the regulatory Provider Bulletin published in the December 2005 Medi-Cal Update, DHCS has established procedures for the enrollment of physicians who are solely employed by or provide services pursuant to a contract with licensed primary care clinics, except for services provided as part of a graduate medical education program, and who do not have any active Medi-Cal provider number issued to them individually to bill for clinical services to Medi-Cal beneficiaries at another location and as such, use the licensed primary care clinic as their established place of business. This type of enrollment allows the physician to bill for inpatient services only and not for services provided at the Licensed Primary Care Clinic. In order to determine whether or not you qualify for this type of enrollment, please read the detailed Provider Bulletin: “Requirements and Procedures for ‘Clinic-Based Provider’ Enrollment”. 

 

If you qualify to enroll as a Clinic-Based Physician: Clinic-Based Physicians are required to submit their individual and/or group applications via PAVE (Provider Application and Validation for Enrollment).

许可

在申请 Medi-Cal 之前，请先查看加州医学委员会或加州整骨医学委员会，以确保您符合所有执照要求。      

所需文件

接下来，收集下面列出的所需文件（如适用），以便在完成 PAVE 申请时将它们上传到 PAVE。 请确保上传的文件清晰易读。

• 申请人或服务提供者的有效加州行医执照或整骨医师及外科医生执照。如有，请附上美国缉毒局（DEA）颁发的证书。
• Driver’s License or state-issued identification card (issued within the 50 United States or the District of Columbia) of the provider who is signing the application. The signature must be that of the physician applicant. 
• 如果未使用社会保障号码，则需提交由美国国税局 (IRS) 出具的最新文件，以验证医生申请人的联邦雇主识别号码 (FEIN) 或个人纳税人识别号码 (ITIN) 。唯一可接受的文件包括 IRS 出具的 147-C 号信函、IRS 出具的 941 表格（雇主季度联邦纳税申报表）、IRS 出具的 8109-C 表格（存款凭证）或 IRS 出具的 SS-4 表格（仅限 FEIN/ITIN 分配的正式确认通知）。注意：申请表上申请人或提供者的法定姓名必须与国税局出具的文件上的姓名完全一致；并且申请人/提供者必须是国税局文件中所列实体的所有者或负责人。如需了解更多信息，请访问美国国税局网站或致电 (800) 829-4933。
• Licensed Primary Care Clinic Cover Letter from at least one Medi-Cal-enrolled clinic at which you provide services. This letter should include the required information as described on page three of the Clinic-Based Provider Bulletin.   
• Physician Cover Letter (at least one) that includes the required information as described on page four of the Clinic-Based Provider Bulletin.  
• Fictitious Name Permit (FNP) issued by the Medical Board of California or the Osteopathic Medical Board of California, if using a fictitious name for your medical practice, as defined by the Board.  Note: The business name of the applicant or provider on the application, all local business licenses/permits, and the FNP must exactly match.
• If your business is a corporation, processing delays may be avoided by attaching a copy of the filed Articles of Incorporation from the Secretary of State, 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 or status of your corporation, or for further information, please visit the Secretary of State California Business Portal select the “California Business Search” link or other appropriate link.
• 专业责任保险证书，每次索赔的保额不少于 100,000 美元，每年最低累计保额为 300,000 美元。 可接受的验证是保险公司出具的保险证明或声明单，其中包含保险公司的名称、被保险人的姓名、生效日期和承保限额。 注意：医疗服务提供者的姓名（如加州医疗执照上所显示的）也必须显示在专业责任保险的验证上。

PAVE 门户

继续前往PAVE门户。