醫生擁有的外科中心或外科診所申請信息
If your surgery center does not have any percentage of ownership by physicians, then you need to contact the California Department of Public Health’s Licensing and Certification Division for information regarding enrolling as a Medi-Cal provider, instead of enrolling through PED.
醫生擁有的外科中心和外科診所提供者必須通過 PAVE（提供者申請和註冊驗證）提交個人和/或團體申請。
申請費
Effective January 1, 2013, applicants requesting enrollment as a Physician-Owned Surgery Center or Surgical 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 455.460Regulatory 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.
認可及聯邦醫療保險認證
在申請加州醫療補助健康保健計劃之前，您的手術中心/診所必須獲得聯邦醫療保險認證的批准。 外科診所可以透過加州醫療委員會網站上列出的聯邦醫療保險和醫療補助服務中心 (CMS) 批准的認證組織尋求聯邦醫療保險認證資格。
所需文件
接下來，請收集下列適用的必要文件，以便在完成 PAVE 申請時將其上傳到 PAVE 系統。請確保上傳的檔案清晰可讀。
1.聯邦醫療保險認證批准。
2. 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。
3.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 IRS or call them at (800) 829-4933.
4. 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 Web site, click on the “California’s Counties” link, and select “County Web Sites.”
5. 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 Web site, click on the “California’s Counties” link, and select “County Web Sites.” on the “California’s Counties” link, and select “County Web Sites.”
6.Seller’s Permit issued by the California State Board of Equalization, if applicable. 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.
7. Fully executed Partnership Agreement, if your business is a partnership. 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。
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.
8. 如果您的企業是公司，可以透過附上州務卿處備案的公司章程副本，以及董事和高階主管的姓名和職位清單（包括每個人的所有權和控制權百分比）來避免處理延誤。如需核實或更改公司名稱和/或狀態，或了解更多信息，請訪問加州州務卿商業門戶網站，點擊“加州企業搜尋”鏈接或其他相關連結。
9.商業責任保險證明（商業責任險、一般責任險、綜合責任險或辦公室保險），每次索賠金額不少於 100,000 美元，年度累計金額不低於 300,000 美元。可接受的證明文件可以是自保證明，也可以是保險公司簽發的保險證明或聲明單，其中包含保險公司的名稱、被保險人的姓名和營業地址、生效日期和承保範圍。注意：申請表上的申請人或提供者的姓名和營業地址（如適用，包括套房號碼）必須與保險證明或聲明單上的被保險人的姓名和地址完全一致。
10.Certificate of Professional Liability Insurance in an amount of not less than $100,000 per claim and a minimum annual aggregate of $300,000. 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, as it appears on the California Clinical Laboratory License, must also show on the verification of the professional liability insurance.
11.Certificate of Workers’ Compensation Insurance is required by California law, if your business has one or more employees. 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, and effective dates. If no Workers’ Compensation insurance is required, an explanation must be provided. Note: The name and business address of the applicant or provider must exactly match the insured’s name and address on the certificate of insurance.
12.Signed Lease Agreement, if business premises are not owned by the applicant or provider. Note: The name and business address of the applicant or provider must exactly match the lessee’s name and address on the lease agreement.
13.繼承人責任及連帶責任協議（ DHCS 6217 ），如適用。