Get Ca Participating Professional/ancillary Application 1997-2026

Completing the California Participating Professional/Ancillary Application online is essential for healthcare professionals seeking participation with Kern Health Systems. This guide provides clear and detailed instructions on how to efficiently fill out the application.

Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to retrieve the application form and open it in your preferred digital editor.
2. Begin by filling out your identifying information. Include your last name, first name, middle name, and any other names you have been known by. Enter your home address, telephone number, fax number, email address, pager number, birth date, birthplace, citizenship status, social security number, gender, specialty, and race/ethnicity if you choose to disclose this information.
3. Complete the practice information section. Provide the name of your practice if applicable, your primary office address, telephone number, fax number, office manager’s contact information, associated tax ID number, and federal tax ID number.
4. Document your medical, nursing, or professional education. Specify the medical school attended, the degree received, the mailing address, and the date of graduation. Repeat this step for any additional medical or professional schools.
5. Enter your professional licensure and registrations. Include your state medical license number, issue date, expiration date, DEA registration number, and controlled substances certificate expiration date if applicable.
6. List all other state medical licenses you hold or have previously held, including the state, license number, and expiration date.
7. Provide details of your current professional liability insurance. Fill in the insurance carrier name, policy number, mailing address, original effective date, per claim amount, aggregate amount, and expiration date. Remember to attach a copy of your professional liability policy or certification face sheet.
8. Include three professional references from your specialty, as outlined in the application guidelines. Provide each reference's name, specialty, mailing address, and telephone number.
9. Chronologically list your work history since completing your training. Include names of practices/employers, contact names, and their details, while explaining any gaps in your work history on an attachment.
10. Answer the attestation questions carefully, indicating 'yes' or 'no' as applicable. If 'yes', provide detailed explanations on additional sheets.
11. Sign the application, affirming that all information provided is accurate and complete. Note that stamped signatures are not acceptable.
12. Once all sections are completed and verified, save your changes. You can then download, print, or share the completed application as necessary.

Complete your CA Participating Professional/Ancillary Application online today to ensure your participation with Kern Health Systems.