CA Participating Professional/Ancillary Application 1997-2025 free printable template

CONFIDENTIAL/PROPRIETARY California Participating Professional/Ancillary Application This application is submitted to: Kern Health Systems, herein, this Healthcare Organization1 I. INSTRUCTIONS: This

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How to fill out CA Participating Professional/Ancillary Application

1. Obtain the CA Participating Professional/Ancillary Application form from the appropriate regulatory body website.
2. Read the instructions carefully before starting to fill out the application.
3. Provide your personal information, including name, address, and contact details.
4. Indicate your professional qualifications and any relevant certifications.
5. List your employment history and any relevant clinical experience.
6. Complete sections related to your practice details, including specialties and practice location.
7. Disclose any disciplinary actions or legal issues if applicable.
8. Review your application for accuracy and completeness.
9. Sign and date the application form.
10. Submit the application along with any required fees and supporting documents to the appropriate authority.

Who needs CA Participating Professional/Ancillary Application?

1. Healthcare professionals seeking to participate in California's healthcare programs.
2. Ancillary service providers who intend to offer services within a healthcare setting.
3. Clinics and facilities that require credentialing for professionals assisting in patient care.
4. Organizations looking to expand their network of participating providers in California.

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What is CA Participating Professional/Ancillary Application?

The CA Participating Professional/Ancillary Application is a form that healthcare providers submit to participate in California's Medi-Cal program, allowing them to provide services to Medi-Cal beneficiaries.

Who is required to file CA Participating Professional/Ancillary Application?

Healthcare professionals and ancillary service providers who wish to participate in Medi-Cal must submit this application.

How to fill out CA Participating Professional/Ancillary Application?

The application must be filled out by providing personal, professional, and business information, including licensing details, practice location, and ownership structure, followed by submission to the appropriate Medi-Cal administrative office.

What is the purpose of CA Participating Professional/Ancillary Application?

The purpose of the application is to assess and verify the qualifications of healthcare providers and ensure compliance with Medi-Cal program regulations.

What information must be reported on CA Participating Professional/Ancillary Application?

The application requires reporting of details such as the provider's name, contact information, professional credentials, business affiliations, and any prior disciplinary actions or criminal convictions.