個人護士提供者（INP）申請要求

• 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
• 消費者事務部 (DCA) 牌照列印
• 有效的國家簽發的身份證件或駕駛執照
• 有效的基本生命支援 (BLS) 認證
• 專業責任（不良行為）保險
• 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.

將完整的申請包提交至：

Department of Health Care Services

綜合護理系統科

提供者註冊單位

國會大道 1501 號，密西西比州大廈 4502

郵政編碼 箱子 997437

加利福尼亞州薩克拉門托 99-7437

請注意：將包裹發送給提供者註冊單位 

不要將任何文件發送給提供者註冊部

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.