Exempt from Licensure Clinic Application Information
Exempt from Licensure Clinics are required to submit their individual and/or group applications via PAVE (
Provider Application and Validation for Enrollment).
A letter should be uploaded with your application in PAVE that states the Health and Safety Code Section that describes your business’ Exempt from Licensure status; should list all equipment registration numbers and proof of registration with the Radiological Health Branch if applicable; should list all of the diagnostic services and the CPT Codes for which you intend to bill; should list the names of the technicians providing the technical component of services (if applicable) and the names of the physicians providing the professional component of services.
Application Fee
Certificate of Registration and Licenses
Prior to applying to Medi-Cal, first check the
Radiologic Health Branch (RHB) site, click on "Programs", then "Radiologic Health Branch" and ensure you meet all the certification, registration and permit requirements as applicable to your clinic. Also, check with the
Medical Board of California
to ensure you meet all the licensing requirements. If applicable, also check with the California Department of Public Health, Lab Field Services Branch at
(510) 620-3800 to ensure you meet all of the licensing requirements.
RHB Radiation Machine Registration
and/or
Mammography Machine Certification;
California Radiology Supervisor Operato Permit(s),
Radiologic Technologist Certificate(s)/License(s) and/or
X-Ray Technologist Permit(s) and/or
Mammographic Radiologic Technologist Certificate(s), as applicable;
current radioactive material license issued by DPH, Radiological Health Branch, as applicable;
current FDA certified mammography facility certificate, as applicable; current
California Medical License for supervising physician(s). All other medical certificates and registrations as required according to the type of equipment being used.
Driver’s License or state-issued identification card (issued within the 50 United States or the District of Columbia) of the provider, or person signing the application who has the authority to legally bind the applicant or provider. The signature must be that of the provider, unless the provider is a corporation. If the provider is a corporation and the application is going to be signed by a person other than the provider, please submit a copy of the section of the corporation’s bylaws that identifies the signing person’s authority to legally bind the corporation.
Driver’s License or state-issued identification card
(issued within the 50 United States or the District of Columbia) of the provider, or person signing the application who has the authority to legally bind the applicant or provider. The signature must be that of the provider, unless the provider is a corporation. If the provider is a corporation and the application is going to be signed by a person other than the provider, please submit a copy of the section of the corporation’s bylaws that identifies the signing person’s authority to legally bind the corporation.
Federal Employer Identification Number (FEIN) or Individual Taxpayer Identification Number (ITIN) verification, if a social security number is not used, by submitting a current Internal Revenue Service (IRS) generated document. The only acceptable documents include an IRS-generated Letter 147-C, IRS-generated Form 941 (Employer’s Quarterly Federal Tax Return), IRS-generated Form 8109-C (Deposit Coupon), or IRS-generated Form SS-4 (only the official Confirmation Notification of FEIN/ITIN assignment). Note: The legal name of the applicant or provider on the application must exactly match the name on the IRS-generated document; and the applicant/provider must be an owner or officer of the entity listed on the IRS document. For further information, please check with the
IRS or call them at (800) 829-4933.
Local Business License, Tax Certificate, and Permit for any city and/or county where business activities are conducted. Note: The name and business address of the applicant or provider on the application must exactly match the business name and business address on all local licenses and permits. If a business license/permit is not required, please submit a written statement from your local city/county indicating that your business does not require any license or permit. For further information, please contact your city business license office and/or visit the
California State Association of Counties and click on the "California’s Counties" link, and select "County Web Sites."
Recorded/stamped Fictitious Business Name Statement (FBNS),
issued by the county where the principal place of business is located, if using a fictitious business name AND the business name is different from the legal name on your application. For example, in the case of a corporation, any name other than the corporation name on record with the Secretary of State requires a FBNS. Note: The business name and business address of the applicant or provider on the application, all local business licenses/permits, and the FBNS must exactly match. To determine the applicable county agency where fictitious business names are filed, please visit the
California State Association of Counties and select the "California’s Counties" link, then select "County Web Sites."
Clinical Laboratory Improvement Amendment (CLIA) Certificate (all pages),
appropriate for the level of testing performed,
if laboratory services are provided. For further information, visit the
Centers for Medicare and Medicaid Services.
State Clinical Laboratory License/Registration, or verification of exemption from licensure/registration,
if laboratory services are provided. Call the Laboratory Field Services office at
(510) 620-3800 to determine what specific forms you are required to submit, and then download these
forms. Pease Note: The name and business address of the applicant or provider on the application, the CLIA Certificate, and the State Clinical Laboratory License/Registration (or exemption) must exactly match.
Fully executed
Partnership Agreement, if your business is a partnership. To verify or change the name and/or status of your partnership or for further information, please visit the
Secretary of State California Business Portal
and click on the "California Business Search" link or other appropriate link. Processing delays may be avoided by indicating whether the entity is a General Partnership or Limited Partnership and also submitting the following:
For a General Partnership, a list of all partners with percentage of ownership or control interest for each; or
For a Limited Partnership, information identifying the General Partner, and a list of all partners with percentage of ownership or control interest for each.
If your business is a corporation, processing delays may be avoided by attaching a copy of
the filed
Articles of Incorporation from the California Secretary of State (or a Statement of Domestic Stock Corporation if your corporation is based outside of California), and a list of directors’ and officers’ names and titles, with percent of ownership and control interest for each. To verify or change the name and/or status of your corporation or for further information, please visit the
Secretary of State California Business Portal and click on the "California Business Search" link or other appropriate link.
Certificate of Commercial Liability Insurance
(business, general, or comprehensive liability, or office premises insurance) in an amount of not less than $100,000 per claim and a minimum annual aggregate of $300,000. Acceptable verification is either evidence of being self-insured, or a certificate of insurance or declaration sheet issued by the insurance company that contains the name of the insurance company, the name and business address of the insured, effective dates, and limits of coverage. Note: The name and business address, including suite number if applicable, of the applicant or provider on the application must exactly match the insured’s name and address on the certificate of insurance or declaration sheet.
Certificate of Professional Liability Insurance
in an amount of not less than $100,000 per claim and a minimum annual aggregate of $300,000 for each licensed individual listed in the application package. Acceptable verification is a certificate of insurance or declaration sheet issued by the insurance company that contains the name of the insurance company, the name of the insured, effective dates, and limits of coverage. Note: The provider’s name(s), as appears on the licensed professional(s) license(s) must also show on the verification of the professional liability insurance.
Certificate of Workers’ Compensation Insurance is required by California law, if your business has one or more employees. Acceptable verification is either evidence of being self-insured, or a certificate of insurance or declaration sheet issued by the insurance company that contains the name of the insurance company, the name and business address of the insured, and effective dates. If no Workers’ Compensation insurance is required, an explanation must be provided. Note: The name and business address of the applicant or provider must exactly match the insured’s name and address on the certificate of insurance.
Successor Liability with Joint and Several Liability Agreement (
DHCS 6217),
if applicable.
PAVE portal
Proceed to the
PAVE portal.
Exempt from Licensure Clinic status change to FQHC:
If you are an exempt from licensure clinic that has changed your status to a Federally Qualified Health Center (FQHC) you must report a Change of Ownership and a
Change of Address using a Medi-Cal
paper application. Please submit the following forms and all required documentation:
Medi-Cal Provider Application (DHCS 6204)
Medi-Cal Provider Disclosure Statement (DHCS 6207)
Medi-Cal Provider Agreement (DHCS-6208)
