Follow the steps to successfully complete the application.

1. Press the ‘Get Form’ button to acquire the form and open it in an online editor.
2. Begin filling out the practitioner identifying information section, which includes your last name, first name, and middle name.
3. Next, move to the case information section. Input the patient’s name, gender, and date of birth, along with the city, county, and state where the lawsuit was filed.
4. Provide the court case number, if known, and indicate the location of the incident such as the hospital or your office. Additionally, specify the date of the alleged incident.
5. Indicate your relationship to the patient and outline the allegations stated in the lawsuit or arbitration.
6. Answer whether there was an insurance company or other liability protection organization involved. If yes, include their contact information and claim identification number.
7. If applicable, provide details regarding your attorney and their contact information, authorizing them to communicate with the healthcare organization.
8. For the status of the lawsuit or arbitration, check the appropriate box that reflects the current state of the case.
9. Summarize the circumstances of the legal action, including patient care specifics, and attach any additional sheets if necessary.
10. Finally, certify that all information provided is accurate and sign the form. Be sure to print your name and date the application.
11. Once you have completed the form, you can save your changes, download the application, print it, or share it according to your needs.

Prepare your documents and fill out the CA Participating Physician Application - Addendum A online today.