Nurse Practitioner Application Information
Nurse Practitioners 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
Doctors of medicine, doctors of osteopathy, physician assistants and nurse practitioners may be combined in a medical group for enrollment purposes.
Licensing
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.
California Registered Nurse License and
Certificate of Nurse Practitioner from a national or state organization acknowledged by California Board of Registered Nursing, and specifying the area of specialization training.
2.
For Rendering Applicants Only: California Medical License of the applicant’s supervising physician and
California Medical License of the applicant’s employing provider, if applicable and if different than the supervising physician.
3.
Driver’s License or state-issued identification cards (issued within the 50 United States or the District of Columbia) for each of the following;
a. The Certified Nurse Practitioner Applicant
b.
For Rendering Applicants only: The supervising physician's driver license or state-issued identification card.
c.
For Rendering Applicants only : The person signing the form for the Employing Provider. The signature must be that of the employing provider, unless the provider is a corporation, governmental entity or non-profit organization. If the employing provider is one of these three entity types and the forms are going to be signed by a person other than the employing 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.
4.
For Rendering Applicants only
: Certified Nurse Practitioner’s Verification of Employment
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.
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 provider’s name, as it appears on the California Registered Nurse License and Nurse Practitioner Certificate, must also show on the verification of the professional liability insurance.
7.
For Individual Application Only:
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.
8.
For Individual Application Only :
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.
9.
For Individual Application Only : Signed Lease Agreement, if business premises are not owned by the applicant or provider. Note: The name and business address of the applicant or provider must exactly match the lessee’s name and address on the lease agreement.
10.
For Individual Application Only:
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."
11.
For Individual Application Only
: 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 click on the "California’s Counties" link, and select "County Web Sites."
12.
For Individual Application Only: 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.
For Individual Application Only: If your business is a partnership, a fully executed
Partnership Agreement. 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.
15.
For Individual Application Only:
Successor Liability with Joint and Several Liability Agreement (DHCS 6217), if applicable.
PROCEED TO
PAVE
