Get California Participating Physician Reappointment Application Form ...

This guide provides a clear and supportive walkthrough for completing the California Participating Physician Reappointment Application Form online. By following these steps, users can ensure they fill out the form accurately and submit it effectively.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Complete the identifying information section. This includes fields for your last name, first name, middle name, mailing address, contact numbers, email address, birth date, and citizenship details. Ensure all information is accurate, and avoid using abbreviations.
3. Provide all necessary documentation as required by the form, such as a copy of your state medical license, DEA certificate, board certification (if applicable), and professional liability insurance details.
4. Fill out the practice information section. This will include your primary office address, contact numbers, and the details of any other medical practices or affiliations.
5. Complete the residencies and fellowships section. Include any relevant training you have undertaken in the last two years, specifying whether the programs were completed successfully. Attach additional sheets if necessary.
6. Input your medical license and registration details, including your California state medical license number and DEA registration details.
7. Provide your professional liability insurance information, including carrier name, policy number, and any relevant details about past insurance carriers.
8. List your current hospital and institutional affiliations. Include details of each organization and your status within them.
9. Answer the attestation questions seriously. Respond with 'yes' or 'no' to each question, and provide additional details on a separate sheet if necessary.
10. Review your filled application thoroughly, ensuring all sections are complete and accurate. Save your changes, download, and/or print the form if you need a hard copy.

Complete your documents online to ensure a smooth application process.