Registration Guidance
Clinic Workforce Stabilization Retention Payments
Qualified clinics are required to register with the Department of Health Care Services (DHCS) to participate in Clinic Workforce Stabilization Retention Payments (CWSRP). Once registered, qualified clinics will be approved to apply for retention payments on behalf of eligible employees.
General Guidance:
Registration opens on November 15 and closes on December 28, 2022. Qualified clinics are encouraged to complete registration as soon as possible to minimize delays in approval.
A link to the registration form will be available on the CWSRP webpage on November 15.
If you are part of a large health system, you can register just once using information from your largest clinic or organization (with the largest number of employees), as long as the system entity qualifies and is the employer of all system-wide employees.
Clinics that are not Medi-Cal enrolled providers must complete and submit a Form STD 204, Payee Data Record at time of registration.
There are approximately 10 items to complete on the registration form, depending on your clinic type. Please see the Appendix for required information.
It will take about 15 minutes to complete the registration form.
Things to know before you get started:
Keep your browser open until you have completed registration. Closing your browser before completion will require you to restart the registration.
You must click 'Next' on most pages to continue to the next page.
You can return to the previous page by clicking 'Prev'.
To start the registration process, you will be required to accept the following Disclosure and Privacy Statements before proceeding.
Disclosure of Personal Information: In order to validate identity and qualification for participation in the Clinic Workforce Stabilization Retention Payments (CWSRP), it may be necessary to share information you provide with authorized state/federal agencies or third-party vendors. While it is your choice to complete the registration and application process, failure to complete the entire process will result in the inability to determine eligibility and make corresponding retention payments.
Privacy Notice, Civ. Code section 1798.17: The personal information collected on and with this form is confidential, subject to the Department of Health Care Services (DHCS) Notice of Privacy Practices that can be found here: https://www.dhcs.ca.gov/formsandpubs/laws/priv/Documents/Notice-of-Privacy-Practices-English.pdf. DHCS needs the information to administer the CWSRP. DHCS will not use or share the information for other purposes except with your permission or as permitted by law. You must provide all information requested on this form. If you do not provide all information requested, we may not be able to decide if you qualify for payment. In most cases, the individual(s) to whom this information pertains has the right to access it. DHCS is authorized to collect this information pursuant to Labor Code section 1492. This privacy notice provided here is required by California Civil Code section 1798.17.
- To complete the registration, you will be asked to confirm the information you have entered and consent to the attestation by entering your first and last name and your title within the organization, and then click the “done" button. A successful submission response will be provided with further instructions.
I declare under penalty of perjury, under the laws of the State of California, that the foregoing information in this document and any attachments is true, accurate, and complete to the best of my knowledge and belief. I am authorized to submit this information on behalf of the applicant. I understand by typing the first and last name in the box below constitutes my electronic signature.
Note: The authorized attestor must be a partner, corporate officer, or an official representative of the qualified clinic who has the authority to legally bind the applicant.
- After registration submission, the qualified clinics will receive an email from DHCS confirming that their registration has been accepted or that additional information is required.
Selecting your clinic type:
Be sure to select the clinic type that best reflects your organization. If you have more than one clinic type described below with the same name, Tax Identification Number (TIN), or Federal Employer Identification Number (FEIN), select the clinic type with the largest group of employees.
Federally Qualified Health Center (FQHC): Federally funded nonprofit health centers or clinics that serve medically underserved areas and populations. FQHCs provide primary care services regardless of your ability to pay.
Rural health clinic (RHC): A clinic located in a rural, underserved area with a shortage of primary care providers, personal health services, or both, and which provides primary care and preventive health services in underserved rural areas.
FQHC look-alike: An organization that meets all of the eligibility requirements of a FQHC that receives a Public Health Service (PHS) Section 330 grant, but does not receive grant funding.
Tribal FQHC: A clinic that provides covered primary care clinic services to Medi-Cal patients. Tribal FQHC services may be provided in a clinic or offsite by Tribal providers and non-Tribal providers that are contractors of the Tribal FQHC.
Indian health clinic: An operating division within the U.S. Department of Health and Human Services responsible for providing direct medical and public health services to members of federally recognized Native American Tribes and Alaska Native people. This definition also covers Indian health clinics on Tribal land adjacent to California in a neighboring state that provides services to American Indians and their families who reside in California.
Free clinic: A clinic that provides medical care, counseling, dental care, and legal assistance to individuals and families in need, regardless of their ability to pay. This includes people of all ages, ethnicities, religious, and socioeconomic backgrounds who are unable to use traditional sources within the community.
Definitions:
| Contact Person (used for Contact Name, Contact Email Address, and Contact Phone Number) | The contact person should be the individual who DHCS may contact, if needed, regarding your registration form.
The email address will be used for all DHCS correspondence regarding your registration status and next steps. |
| NPI | National Provider Identifier: a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare & Medicaid Services (CMS). |
| TIN/FEIN | Tax Identification Number or Federal Employer Identification Number: a federal identification number that appears on your W9 form. |
Payee Entity Type (as defined by the State of California – Department of Finance) | Single Member LLC – owned by an individual: Limited Liability Company (LLC) owned by an individual and is disregarded for federal tax purposes. Partnerships: Partnerships * Limited Liability Partnerships (LLP) * and LLC treated as a Partnership Estate or Trust: Estate * Trust (other than disregarded Grantor Trust). Corporation – Medical: Corporation that is medical in nature (e.g., medical and health care services, physician care, nursery care, dentistry, etc.) * LLC that is to be taxed like a corporation and is medical in nature. Corporation – Legal: Corporation that is legal in nature (e.g., services of attorneys, arbitrators, and notary publics involving legal or law-related matters, etc.) * LLC that is to be taxed like a corporation and is legal in nature. Corporation – Exempt: Corporation that qualifies for an Exempt status, included 501(c) 3 and domestic nonprofit corporations. Corporation – All Others: Corporation that does not meet the qualifications of any of the other corporation types listed above. * LLC that is to be taxed as a corporation and does not meet any of the other corporation types listed above. |
| Intermittent Clinic | A clinic that is operated by a primary care community clinic or free clinic that is operated on separate premises from the licensed clinic and is only open for limited services of no more than 40 hours a week. This clinic type is not listed as a choice on registration since it falls under the license of a FQHC, FQHC look-alike, Indian health clinic, or free clinic.
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For more information, please visit the Clinic Workforce Stabilization Retention Payments webpage on the DHCS website and review the Frequently Asked Questions (FAQs).
Appendix: Required Information
The following information is required on the registration form.
- Contact name (first and last)
- Contact email address and phone number
- Clinic type (FQHC, RHC, FQHC look-alike, Tribal FQHC, Indian health clinic, Free clinic)
- Clinic name or business/legal name associated with the TIN/FEIN (as it appears on Internal Revenue Service (IRS) form W9)
- NPI number
- TIN/FEIN
- Estimated number of qualifying personnel
- Payee data record entity type (e.g., corporation, partnership)
- Completed STD 204 (Payee Data Record) form, if requested
- Attester name and title
