豁免执照诊所申请资料
Exempt from Licensure Clinics are required to submit their individual and/or group applications via PAVE (Provider Application and Validation for Enrollment).
您应该在 PAVE 中随申请上传一封信，其中应说明描述您企业豁免许可状态的健康和安全法规部分；应列出所有设备注册号和放射健康部门的注册证明（如适用）；应列出所有诊断服务和您打算收费的 CPT 代码；应列出提供服务技术部分的技术人员的姓名（如适用）以及提供服务专业部分的医生的姓名。
申请费
Effective January 1, 2013, applicants requesting enrollment as a(n) Exempt from Licensure 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 455.460 Regulatory 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.
注册证书和执照
Prior to applying to Medi-Cal, first check the Radiologic Health Branch (RHB) site, click on “Programs”, then “Radiologic Health Branch” and ensure you meet all the certification, registration and permit requirements as applicable to your clinic. Also, check with the Medical Board of Californiato ensure you meet all the licensing requirements. If applicable, also check with the California Department of Public Health, Lab Field Services Branch at (510) 620-3800 to ensure you meet all of the licensing requirements.
- RHB Radiation Machine Registration and/or Mammography Machine Certification; California Radiology Supervisor Operato Permit(s), Radiologic Technologist Certificate(s)/License(s) and/or X-Ray Technologist Permit(s) and/or Mammographic Radiologic Technologist Certificate(s), as applicable; current radioactive material license issued by DPH, Radiological Health Branch, as applicable; current FDA certified mammography facility certificate, as applicable; current California Medical License for supervising physician(s). All other medical certificates and registrations as required according to the type of equipment being used.
- Driver’s License or state-issued identification card (issued within the 50 United States or the District of Columbia) of the provider, or person signing the application who has the authority to legally bind the applicant or provider. The signature must be that of the provider, unless the provider is a corporation. If the provider is a corporation and the application is going to be signed by a person other than the provider, please submit a copy of the section of the corporation’s bylaws that identifies the signing person’s authority to legally bind the corporation.
- Driver’s License or state-issued identification card (issued within the 50 United States or the District of Columbia) of the provider, or person signing the application who has the authority to legally bind the applicant or provider. The signature must be that of the provider, unless the provider is a corporation. If the provider is a corporation and the application is going to be signed by a person other than the provider, please submit a copy of the section of the corporation’s bylaws that identifies the signing person’s authority to legally bind the corporation.
- 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 check with the IRS or call them at (800) 829-4933.
- 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 and click on the “California’s Counties” link, and select “County Web Sites.”
- 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 and select the “California’s Counties” link, then select “County Web Sites.”
- 如果提供实验室服务，则临床实验室改进修正案 (CLIA) 证书（所有页面）适合所进行的测试级别。 如需更多信息，请访问医疗保险和医疗补助服务中心。
- 请注意：申请表、CLIA 证书以及州临床实验室许可证/注册证上的申请人或提供者的姓名和营业地址必须完全匹配。
- State Clinical Laboratory License/Registration, or verification of exemption from licensure/registration, if laboratory services are provided. Call the Laboratory Field Services office at (510) 620-3800 to determine what specific forms you are required to submit, and then download these forms. Pease Note: The name and business address of the applicant or provider on the application, the CLIA Certificate, and the State Clinical Laboratory License/Registration (or exemption) must exactly match.
- Fully executed Partnership Agreement, if your business is a partnership. 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. Processing delays may be avoided by indicating whether the entity is a General Partnership or Limited Partnership and also submitting the following:
- 对于普通合伙企业，需提供所有合伙人的名单，以及每个合伙人的所有权或控制权百分比；或
- 对于有限合伙企业，提供识别普通合伙人的信息，以及所有合伙人的名单以及每个合伙人的所有权或控制权百分比。
- If your business is a corporation, processing delays may be avoided by attaching a copy of the filed Articles of Incorporation from the California Secretary of State (or a Statement of Domestic Stock Corporation if your corporation is based outside of California), 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 and/or status of your corporation 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.
- Certificate of Commercial Liability Insurance (business, general, or comprehensive liability, or office premises insurance) in an amount of not less than $100,000 per claim and a minimum annual aggregate of $300,000. 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, effective dates, and limits of coverage. Note: The name and business address, including suite number if applicable, of the applicant or provider on the application must exactly match the insured’s name and address on the certificate of insurance or declaration sheet.
- Certificate of Professional Liability Insurance in an amount of not less than $100,000 per claim and a minimum annual aggregate of $300,000 for each licensed individual listed in the application package. 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(s), as appears on the licensed professional(s) license(s) must also show on the verification of the professional liability insurance.
- 如果您的企业有一名或多名员工，则加州法律要求您的企业提供工伤赔偿保险证明。 可接受的证明是自保证据，或保险公司出具的保险证明或声明表，其中包含保险公司的名称、被保险人的姓名和营业地址以及生效日期。 如果不需要工伤赔偿保险，则必须提供解释。 注意：申请人或提供商的名称和营业地址必须与保险凭证上的被保险人的姓名和地址完全一致。
- 承担连带责任协议的继任责任（ DHCS 6217 ）（如适用）。
PAVE 门户
继续前往PAVE门户。
Exempt from Licensure Clinic status change to FQHC:
If you are an exempt from licensure clinic that has changed your status to a Federally Qualified Health Center (FQHC) you must report a Change of Ownership and a
Change of Address using a Medi-Cal paper application. Please submit the following forms and all required documentation:
- Medi-Cal 提供商申请表(DHCS 6204)
- Medi-Cal 提供商披露声明(DHCS 6207)
- Medi-Cal 提供商协议(DHCS-6208)