California Participating Physician Form PDF Details

Beginning January 1, 2020, all California healthcare providers who participate in the state's Medicaid program, Medi-Cal, will be required to use the California Participating Physician Form (CPDF) for all billings and claims submissions. The CPDF is a standardized form that was created to improve communication between providers and the Medi-Cal program office. Use of this form will help to ensure accuracy and completeness of provider information on billing claims. Providers are encouraged to familiarize themselves with the requirements of using the CPDF before January 1, 2020. For more information on how to use the CPDF, please visit our website or contact our customer service department. Thank you for your continued partnership with Medi-Cal!

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

Form Preview Example

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

Form Preview Example

California Participating Physician Form isn’t the one you’re looking for?

California Participating Physician Form – Fill Out and Use This PDF

California Participating Physician Form PDF Details

Form Preview Example

California Participating Physician Form isn’t the one you’re looking for?

Related Documents