豁免執照診所申請信息
Exempt from Licensure Clinics are required to submit their individual and/or group applications via PAVE (Provider Application and Validation for Enrollment).
申請時，應在 PAVE 系統中上傳一封信函，信函中應說明貴公司免於執照申請的健康與安全法規章節；應列出所有設備註冊號碼以及（如適用）放射衛生部門的註冊證明；應列出所有診斷服務以及您打算開具賬單的 CPT 代碼；應列出提供服務技術部分的技師姓名（如適用）以及提供服務專業部分的醫生姓名。
申請費
自 1 月 1、2013 日起，申請註冊為免執照診所的申請人須在提交申請時繳納申請費。《聯邦法規第 42 章第 455.460 條監管提供者公告》中關於 Medi-Cal 申請費要求的具體資訊提供了有關此要求的具體資訊。有關當前申請費信息，請參閱 Medi-Cal 提供者註冊部門頁面的資源部分。
註冊證書及牌照
在申請Medi-Cal之前，請先查看放射健康分部 (RHB)網站，點擊“ Program ”，然後點擊“放射健康分部”，確保您滿足適用於您診所的所有認證、註冊和許可要求。 另外，請向California醫學委員會核實，以確保您符合所有執照要求。 如適用，也請與California公共衛生部實驗室現場服務處聯繫（510）620-3800，以確保您符合所有許可要求。
- 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.
- 提供者的駕駛執照或州政府頒發的身份證（在美國 50 個州或哥倫比亞特區頒發），或簽署申請且有權代表申請人或提供者簽署申請的人的身份證。除非提供者是公司，否則簽名必須是提供者本人的簽名。如果提供方是公司，而申請將由提供者以外的人簽署，請提交公司章程中明確簽署人有權代表公司簽署申請的章節副本。
- 提供者的駕駛執照或州政府頒發的身份證（在美國 50 個州或哥倫比亞特區頒發），或簽署申請且有權代表申請人或提供者簽署申請的人的身份證。除非提供者是公司，否則簽名必須是提供者本人的簽名。如果提供方是公司，而申請將由提供者以外的人簽署，請提交公司章程中明確簽署人有權代表公司簽署申請的章節副本。
- 如果未使用社會安全號碼，則需提交美國國稅局 (IRS) 簽發的最新文件，以驗證聯邦雇主識別號碼 (FEIN)或個人納稅人識別號碼 (ITIN)。唯一可接受的文件包括 IRS 簽發的 147-C 號信函、IRS 出具的 941 表格（雇主季度聯邦納稅申報表）、IRS 出具的 8109-C 表格（存款憑證）或 IRS 出具的 SS-4 表格（僅限 FEIN/ITIN 分配的正式確認通知）。注意：申請表上申請人或提供者的法定姓名必須與國稅局所發出的文件上的姓名完全一致；且申請人/提供者必須是國稅局文件中所列實體的所有者或負責人。如需了解更多信息，請諮詢美國國稅局或致電 (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.”
- 如果使用虛構的商業名稱，且該商業名稱與申請中的法定名稱不同，則需要提供由主要營業場所所在縣簽發的已登記/蓋章的虛構商業名稱聲明（FBNS）。例如，對於公司而言，除州務卿處登記的公司名稱外，任何其他名稱都需要 FBNS。注意：申請表上的申請人或提供者的企業名稱和企業地址、所有當地營業執照/許可證以及 FBNS 必須完全一致。要確定提交虛構商業名稱的適用縣級機構，請訪問California州縣協會，選擇“ California州的縣”鏈接，然後選擇“縣級網站”。
- 臨床實驗室改善修訂（CLIA）證書（全頁），適合所進行的測試水平（如提供實驗室服務）。 如需了解更多信息，請訪問聯邦醫療保險和醫療補助服務中心。
- 請注意：申請表、CLIA 證書和州臨床實驗室許可證/註冊上的申請人或提供者的姓名和營業地址必須完全一致。
- 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:
- 對於一般合夥人，所有合夥人的清單，其中包含每個合夥人的所有權或控制權益百分比；或
- 對於有限合夥人，請提供識別一般合夥人的資訊，以及所有合夥人清單，其中包含每個合作夥伴的所有權或控制權益百分比。
- 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.
- 如果您的企業有一名或多名員工，則加州法律要求提供工傷賠償保險證明。 可接受的驗證是自保證明，或是由保險公司發出的保險證明書或聲明表，其中包含保險公司名稱、受保人的名稱和營業地址以及生效日期。 如果沒有需要工人補償保險，則必須提供解釋。 註：申請人或提供者的姓名和營業地址必須完全符合保險證書上的受保人姓名和地址。
- 具有連帶責任協議的繼承人責任( DHCS 6217 )（如果適用）。
鋪路門戶
前往 P AVE 門戶。
免於執照變更診所狀態為 FQHC：
如果您是免於執照申請的診所，並且已將自身狀態變更為聯邦合格醫療中心 (FQHC)，則您必須報告所有權變更和
使用 Medi-Cal紙質申請表更改地址。請提交以下表格及所有必需文件：
- 加州醫療補助健康保健計劃提供者申請( DHCS 6204)
- Medi-Cal 提供者揭露聲明(DHCS 6207)
- Medi-Cal 服務提供者協議(DHCS-6208)