FYING INFORMATION Last Name: First: Middle: Medical Group (s) /IPA(s) Affiliation: Do you intend to serve as a primary care provider? Do you intend to serve as a specialist? Please check all that apply: Solo Practice Group Practice Yes Yes No No (If yes, please list specialty(s)) Single Specialty Multi specialty II. BILLING INFORMATION Billing Company: Street Address: City: State: Contact: Telephone Number: ( Name Affiliated with Tax ID Number: ZIP: ) Federal Tax ID Number: III. PRA.
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How to fill out the CA Participating Physician Application Addendum A online
Filling out the California Participating Physician Application Addendum A online is a straightforward process that allows healthcare providers to submit their information efficiently. This guide provides clear instructions for each section of the form to ensure all users can complete it accurately and thoroughly.
Follow the steps to complete the application online:
- Click ‘Get Form’ button to obtain the form and open it in your editor.
- Begin by completing the identifying information section. Fill in your last name, first name, and middle name. Also, indicate your medical group or IPA affiliation and whether you intend to serve as a primary care provider or specialist. Check the appropriate boxes for practice type.
- In the billing information section, enter your billing company's details, including the street address, city, state, and ZIP code. Provide the contact name and telephone number, as well as the federal tax ID number.
- Complete the practice information section. Indicate if you employ any allied health professionals, providing details if applicable. Also, state if you personally employ any physicians and list their names and California medical license numbers if applicable.
- List any clinical services you perform or do not perform that are related to your specialty. Specify if your practice is limited to certain ages.
- Indicate your certifications, such as being a qualified medical examiner, participation in electronic data interchange, or using practice management software.
- Complete the office hours section by indicating when your office is open for each day of the week.
- In the coverage of practice section, list your answering service company and covering physicians, including their contact details. If you lack hospital privileges, provide a written plan for continuity of care.
- Specify any foreign languages spoken fluently by you or your staff.
- If you provide laboratory services, fill in the details including tax ID number, type of service, and indication of whether you have a CLIA certificate or waiver.
- In the professional organizations section, list any medical societies or organizations of which you are a member or applicant.
- Finally, certify the accuracy of your information by printing your name, providing your signature, and entering the date. Remember that stamped signatures are not acceptable.
Take the next step in your professional journey by completing the CA Participating Physician Application Addendum A online.
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What is California participating physician reapplication?
California Participating Physician Reapplication (CPPR) is a program designed to help healthcare providers in California maintain their participation in Medicare and Medi-Cal.
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