药房供应商申请信息
Pharmacies are required to submit their individual and/or group applications via PAVE (Provider Application and Validation for Enrollment).
For information on Fee-for-Service enrollment for Medi-Cal Pharmacies using PAVE, please see the Medi-Cal Fee-for-Service Enrollment for Pharmacies Using the PAVE Online System PowerPoint.
申请费
Effective January 1, 2013, applicants requesting enrollment as a Pharmacy Provider 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.
许可
在申请 Medi-Cal 之前，请先检查加州药房委员会以确保您满足所有许可要求。
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。
- California Pharmacist License for Pharmacist-in-charge and a California State Board of Pharmacy/Clinic Permit, which includes the name(s) of the Pharmacist(s)-In-Charge. As applicable, the DEA Controlled Substance Registration Certificate and the Bureau of Home Furnishings and Thermal Insulation License.
- 提供商或签署申请且有权对申请人或提供商具有法律约束力的人员的驾驶执照或州政府颁发的身份证（在美国 50 个州或哥伦比亚特区内颁发）。 签名必须是提供商的签名，除非提供商是公司。 如果提供商是公司，并且申请将由提供商以外的人员签署，请提交公司章程中指明签署人对公司具有法律约束力的权力的部分的副本。
- Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver and Certificate of California Clinical Laboratory Registration, if applicable, for CLIA-waived tests provided within the pharmacist’s scope of practice as defined by the California State Board of Pharmacy and authorized in Business and Professions Code Section 4052.4. For more information, please reference the regulatory provider bulletin titled, “Medi-Cal Enrollment Requirements and Procedures for Pharmacy Providers That Hold A Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver.”
- 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 visit 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. Select the “California’s Counties” link, then 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 “California’s Counties” link, “California’s Counties” link, then select the “County Web Sites.”
- Seller’s Permit issued by the California State Board of Equalization. Note: The business name and business address of the applicant or provider on the application must match the business name and business address on the seller’s permit. For further information, visit the Board of Equalization or call them at (916) 445-6362. N.B. “Closed door” pharmacy that only sells Prescription Drugs to Residential or LTC facilities does not require seller’s permit.
- 如果您的企业是合伙企业，则需要完全执行合作协议。 可以通过指明实体是普通合伙企业还是有限合伙企业并提交以下文件来避免处理延迟：
- 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。
- To verify or change the name and/or status of your partnership or for further information, please visit the Secretary of State California Business Portaland click on the “California Business Search” link or other appropriate link.
- If your business is a corporation, processing delays may be avoided by attaching a copy of the filed “Articles of Incorporation” and the “Statement of Information for a Domestic Stock Corporation” from the Secretary of State, with the percent of ownership and control interest listed for each director and officer. 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 all forms must exactly match the insured’s name and address on the certificate of insurance or declaration sheet.
- 商业责任保险证明（商业、一般或综合责任或办公场所保险），每次索赔的金额不少于 100,000 美元，每年最低累计金额为 300,000 美元。 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、生效日期和承保限额。 注意：申请表上的申请人或提供商的姓名和营业地址（包括套房号码（如适用））必须与保险证书或申报单上的被保险人的姓名和地址完全一致。
- 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。
- 如果营业场所不属于申请人或提供者所有，则需要签署租赁协议。 注意：申请人或提供商的姓名和营业地址必须与租赁协议上的承租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
Proceed to the PAVE portal