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Group Provider Application Information​

A group provider is defined as two or more rendering providers doing business together under a group provider number at the same business address. When applying as a group provider, in addition to the group provider application, a complete rendering provider application must be submitted for each individual provider not enrolled in Medi-Cal who is rendering services for the group.

Group providers are required to submit their individual and/or group applications via PAVE (Provider Application and Validation for Enrollment)​​​​. If you are submitting a group application, please ensure you also submit at least two rendering applications in PAVE in order to form your group. ​  

Licensing

Prior to applying to Medi-Cal, first check the Licensing requirements on the licensing board website that applies to your provider type.

Required Documents

Next, gather the required documents listed below, as applicable, in order to upload them into PAVE as you complete your PAVE application. Please ensure the uploaded documents are legible. 

1. Fictitious Name Permit (FNP) if required by your licensing board and/or Fictitious Business Name Statement (FBNS), issued by the county where the business is located, if using a fictitious name. In the case of a corporation, any fictitious business name other than the corporation name on record with the Secretary of State requires a FBNS. To determine the applicable county agency where fictitious business names are filed, please visit the California State Association of Counties and click on the "California’s Counties" link, and select "County Web Sites."

2. Clinical Laboratory Improvement Amendment (CLIA) Certificate (all pages), appropriate for the level of testing performed, if laboratory services are provided at your office. For further information, visit the Centers for Medicare and Medicaid ServicesNote: The name and business address of the applicant or provider on the application, the CLIA Certificate, and the State Clinical Laboratory License/Registration must exactly match.

3. 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.

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.

4. 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 provider group. The signature must be that of the provider, unless the provider is a corporation, governmental entity or non-profit organization. If the provider is one of these three entity types and the application are going to be signed by a person other than the provider, please submit documentation that identifies the signing person’s authority to legally bind the corporation or non-profit organization or to represent the governmental entity.

5.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 visit the IRS or call them at (800) 829-4933.​

6. 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."

7. Seller’s Permit issued by the California State Board of Equalization, if applicable. Note: The business name and business address of the applicant or provider on the application must match the business name and business address on the seller’s permit. For further information, visit the Board of Equalization or call them at (916) 445-6362. 

8. 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 all forms must exactly match the insured’s name and address on the certificate of insurance or declaration sheet.

9. Certificate of Professional Liability Insurance in an amount of not less than $100,000 per claim and a minimum annual aggregate of $300,000. 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 group provider’s name, as it appears on the FNP or FBNS, the California Clinical Laboratory License, and professional licenses, must match the name on the verification of the professional liability insurance for the group.

10. 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.

11. Signed Lease Agreement, if business premises are not owned by the applicant or provider. Note: The name and business address of the provider group must exactly match the lessee’s name and address on the lease agreement.

12. Fully executed Partnership Agreement, if your business is a partnership. Processing delays may be avoided by indicating whether the entity is a General Partnership or Limited Partnership and also submitting the following:

a) For a General Partnership, a list of all partners with percentage of ownership or control interest for each; or

b) For a Limited Partnership, information identifying the General Partner, and a list of all partners with percentage of ownership or control interest for each.

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. ​

13. If your business is a corporation, processing delays may be avoided by attaching a copy of the filed Articles of Incorporation from the Secretary of State, 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.

14. Successor Liability with Joint and Several Liability Agreement (DHCS 6217), if applicable.

15. If you are enrolling as a Facility-Based Provider Group, please ensure you meet the other specific enrollment requirements and submit all additional required documentation. For further information, visit the Medi-Cal  and click on the "Provider Enrollment" link, and then "Statutes, Regulations and Provider Bulletins."  

PROCEED TO PAVE ​​​                                                                                                        

Last modified date: 4/4/2022 12:33 PM