California Participating Physician Form – Fill Out and Use This PDF

The California Participating Physician Application Addendum A is a comprehensive form that physicians in California complete to join healthcare organizations or networks such as Health Plans and Independent Practice Associations (IPAs)/Medical Groups. It details various aspects of a practitioner's professional credentials, practice information, services, billing details, and more, making it an essential document for both the healthcare provider and the organization. To help facilitate seamless integration into healthcare networks and ensure the delivery of quality care to patients, filling out this form accurately is crucial.

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California Participating Physician Form PDF Details

The California Participating Physician Application Addendum A serves as a critical document within the healthcare sector, streamlining the interaction between physicians, health plans, and Independent Practice Associations (IPAs)/Medical Groups. It meticulously gathers comprehensive data, starting from basic identifying information such as the physician's name, license number, and whether they intend to serve as a primary care provider or a specialist, including the specific fields they specialize in. Critical to both operational logistics and quality care delivery, it delves into billing information, the structure of the practice (e.g., solo, group, single specialty, or multi-specialty settings), and whether the practice employs allied health professionals or other physicians. Moreover, it seeks details about clinical services offered or omitted by the practice, any age-specific limitations, and the type of anesthesia provided. It underscores the importance of practice accessibility by querying office hours, coverage plans, answering services, and hospital privileges arrangements, ensuring that patient care continuity is maintained. Furthermore, the document inquires about the languages spoken by the physician and staff, direct laboratory services, including compliance with the Clinical Laboratory Information Act (CLIA), and membership in professional organizations. This thorough vetting process not only facilitates the alignment of physicians with healthcare organizations but also ensures compliance with regulatory standards, elevates the quality of patient care, and fosters efficient healthcare service delivery. Lastly, the form demands certification of the truthfulness and accuracy of the provided information, underscoring the seriousness and legal implications of the document.

Question	Answer
Form Name	California Participating Physician Form
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	name telephone participating template, participating application ipa download, number application participating online, physician name california search

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License Number:

Type of Provider:

CONFIDENTIAL/PROPRIETARY

California Participating Physician Application

ADDENDUM A

Health Plans and IPA’s/Medical Groups

This Addendum is submitted to:		herein, this Healthcare Organization. 1

	I. IDENTIFYING INFORMATION

	Last Name:		First:		Middle:

	Medical Group (s) /IPA(s) Affiliation:

	Do you intend to serve as a primary care provider?		Yes	No
	Do you intend to serve as a specialist?		Yes	No (If yes, please list specialty(s))

Please check all that apply:

Solo Practice Group Practice

Single Specialty Multi specialty

II. BILLING INFORMATION

Billing Company:

Street Address:	City:

	State:		ZIP:

Contact:	Telephone Number: (	)

Name Affiliated with Tax ID Number:	Federal Tax ID Number:

III. PRACTICE INFORMATION

Do you employ any allied health professionals (e.g. nurse practitioners, physician assistants, psychologists, etc.)? No

If so, please list:

Name:

Yes

If you are a Physician Assistant Supervisor, please include State License Number:

Do you		personally employ any physicians (do not include physicians that are employed by the medical group)?
	No
If so, please list:
Name:			California Medical License Number:
	__			__
	__			__

Yes

The term “this Healthcare Organization” shall refer to the entity to which this Addendum is submitted as identified above.

California Participating Physician Application Addendum A - 05/97	Page 1 of 3
Physician Name:

Please list any clinical services you perform that are not typically associated with your specialty:

Please list any clinical services you do not perform that are typically associated with your specialty:

Is your practice limited to certain ages?

Yes

If yes, specify limitations:

Are you a Certified Qualified Medical Examiner (QME) of the State Industrial Medical Council?

Yes

Do you participate in EDI (electronic data interchange)?

Yes

If so, which Network?

Do you use a practice management system/software:

Yes

If so, which one?

What type of anesthesia do you provide in your group/office?

Local

Regional

Conscious Sedation

General

None

Other (please specify)

Has your office received any of the following accreditations, certifications or licensures?

American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)

California Department of Health Services Licensure

Institute for Medical Quality-Accreditation Association for Ambulatory Health Care (IMQ-AAAHC)

Medicare Certification

The Medical Quality Commission (TMQC)

Other

IV. OFFICE HOURS- Please indicate the hours your office is open:

Monday	Tuesday	Wednesday	Thursday	Friday

Saturday

Sunday

Holidays

V.COVERAGE OF PRACTICE (List your answering service and covering physicians by name. Attach additional sheets if necessary)

Answering Service Company:	Phone Number: (		)		Fax Number: (		)

Mailing Address:		City:

		State:				ZIP:

Covering Physician's Name:		Telephone Number:		(	)

Covering Physician's Name:		Telephone Number:		(	)

Covering Physician's Name:		Telephone Number:		(	)

Covering Physician's Name:		Telephone Number:		(	)

If you do not have hospital privileges, please provide written plan for continuity of care:

California Participating Physician Application Addendum A - 05/97	Page 2 of 3
Physician Name:

California Participating Physician Application Addendum A - 05/97	Page 3 of 3
Physician Name:

VI. FOREIGN LANGUAGES SPOKEN

Fluently by Physician:

Fluently by Staff:

VII. LABORATORY SERVICES

If you provide direct laboratory services, please indicate the TIN utilized and provide Clinical Laboratory Information Act (CLIA) information. Attach a copy of your CLIA certificate or waiver if you have one.

Tax ID #:	Billing Name:	Type of Service Provided:

Do you have a CLIA certificate?	Yes	No

Do you have a CLIA waiver?	Yes	No

Certificate Number:		Certificate Expiration Date:

VIII. PROFESSIONAL ORGANIZATIONS

Please list country, state or national medical societies, or other professional organizations or societies of which you are a member or applicant.

Organization Name

Applicant

Member

I certify that the information in this document and any attached documents is true and correct.

Print Name Here: _____________________________________________________________________________

Physician Signature: _______________________________________________________________________Date:

(Stamped Signature Is Not Acceptable)

California Participating Physician Application Addendum A - 05/97	Page 4 of 3
Physician Name:

California Participating Physician Form – Fill Out and Use This PDF

California Participating Physician Form PDF Details

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