主页服务长期护理替代方案（家庭和社区服务方案）个人护理提供者 (INP) 申请要求​​ 

个人护理提供者 (INP) 申请要求​​ 

  • 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​​ 
  • 消费者事务部(DCA) 许可证打印件​​ 
  • 有效的州政府签发的身份证或驾驶执照​​ 
  • 有效的基本生命支持 (BLS) 认证​​ 
  • 专业责任（医疗事故）保险范围​​ 
  • 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.​​ 

请将完整的申请材料提交至：​​ 

Department of Health Care Services​​ 

综合护理系统科​​ 

提供者注册单位​​ 

1501 国会大道，密西西比州 4502​​ 

邮局 信箱 997437​​ 

萨克拉门托，加利福尼亚州 95899-7437​​ 

请注意：将包裹寄送至供应商登记部门​​  

请勿向提供商注册部门发送任何文件​​ 

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.​​