The California FNP 004 form is a crucial document used for notifying the Medical Board of California about the renewal or hold release of a fictitious name permit. This form ensures that medical practices comply with state regulations, allowing them to operate under a chosen name while maintaining transparency. To get started on filling out the form, click the button below.
The California FNP 004 form serves as a crucial document for healthcare professionals operating under a fictitious name in the state. This form is primarily used for the renewal or release of a fictitious name permit, which allows medical practitioners to conduct business under a name that differs from their legal name. The form requires essential information, including the current physical practice address, the fictitious name being used, and the unique FNP number associated with the practice. Additionally, it collects details about the ownership structure, whether it be a corporation, partnership, or sole proprietorship, and necessitates signatures from current owners to validate any changes. If there are any holds on the permit, this form must be completed in its entirety to facilitate their removal. It is also important to note that the fictitious name permit is non-transferable; thus, if a practice is sold, both the former and new owners must complete specific applications to ensure the continuity of the business name. The FNP 004 form underscores the importance of accurate record-keeping and compliance with state regulations, ensuring that medical practices operate transparently and responsibly.
MEDICAL BOARD
Sacramento, CA 95815-5401
Licensing Program
2005 Evergreen Street, Suite 1200
O F C A L I F O R N I A
Phone: (916)
263-2382
Fax: (916)
263-2487
Protecting consumers by advancing high quality, safe medical care.
www.mbc.ca.gov
Gavin Newsom, Governor, State of California | Business, Consumer Services and Housing Agency | Department of Consumer Affairs
FICTITIOUS NAME PERMIT
NOTIFICATION OF RENEWAL/HOLD RELEASE
Fictitious Name:
Current Physical
Practice Address:
(No PO Box)
Our records indicate that you are presently doing business as:
FNP #:
SS#/FEIN#:
Phone #:
Renewal Fee: $
Corporation
Partnership
Individual (Sole Proprietor)
A hold has has not been placed on your Fictitious Name Permit. In order for the hold to be removed, this form must be completed in its entirety and signed by a current owner. Refer to the enclosed attachment indicating the current owner(s). Note: A fictitious name permit is not transferable. If a medical practice is purchased by another physician, the
former owner must submit an “Application for Cancellation of a Fictitious Name Permit” to cancel the permit and the new owner must submit a “Fictitious Name Permit Application.” Both forms should be mailed at the same time to assure the name will be available to the new owner.
If you are doing business as a corporation or as a partnership and wish to add/delete shareholders or partners, please provide the following information in the table below. Signatures are required to associate or disassociate shareholders or partners. A signature at the bottom of this form also is required to change the address or renew the permit. Refer to attachment for current owners.
Doctor’s Name (print or type)
License #
Association
Disassociation
Signature
Date
..
+
I declare under penalty of perjury under the laws of the State of California that I have read the foregoing notification and all attachments thereto and know the contents thereof. I have the legal authority to act on behalf of the above-stated entity and the information contained herein is true and correct.
________________________________
______________________________
_____________
____________
Print or Type Name
FNP-004 (Revised 01/2019)
Completing the California FNP 004 form is essential for managing your fictitious name permit. This process ensures that your business information is up to date and compliant with state regulations. Follow these steps carefully to fill out the form correctly.
Once you have filled out the form, it is important to send it to the Medical Board of California along with any required fees. This will ensure that your fictitious name permit is renewed or updated as needed.
What is the California FNP 004 form?
The California FNP 004 form is a notification form used for the renewal or hold release of a fictitious name permit for medical practices. This form is essential for ensuring that the medical practice operates under a recognized fictitious name and complies with state regulations. It must be completed and submitted by the current owner of the permit.
Who needs to fill out the FNP 004 form?
Any medical practice in California that operates under a fictitious name must complete the FNP 004 form. This includes individual practitioners, partnerships, and corporations. If there are changes in ownership, or if the practice needs to renew its permit, this form must be submitted to the Medical Board of California.
What information is required on the FNP 004 form?
The form requires several pieces of information, including the fictitious name under which the practice operates, the current physical practice address (not a P.O. Box), and the FNP number. Additionally, the form requests details about the current owners, including their names and license numbers, as well as any changes in ownership, such as adding or removing partners or shareholders.
What is the renewal fee for the FNP 004 form?
The renewal fee for the FNP 004 form is $X. It is important to submit this fee along with the completed form to ensure the permit remains valid. Be sure to check for any updates to the fee amount, as it may change over time.
Can a fictitious name permit be transferred to another owner?
No, a fictitious name permit is not transferable. If a medical practice is sold, the former owner must cancel their permit by submitting an “Application for Cancellation of a Fictitious Name Permit.” The new owner must then apply for a new permit using the “Fictitious Name Permit Application.” Both applications should be submitted simultaneously to avoid any issues with the name availability.
What happens if there is a hold on the fictitious name permit?
If a hold has been placed on your fictitious name permit, it will need to be resolved before you can continue using that name. To remove the hold, the FNP 004 form must be completed in full and signed by a current owner. It is crucial to ensure that all information is accurate to avoid further delays.
What is the significance of signing the FNP 004 form?
Signing the FNP 004 form is a declaration that the information provided is true and correct. It also confirms that the signer has the legal authority to act on behalf of the entity listed on the form. This signature is vital, as it affirms the commitment to comply with California laws regarding fictitious name permits.
Where should the completed FNP 004 form be submitted?
The completed FNP 004 form should be mailed to the Medical Board of California at the address provided on the form: 2005 Evergreen Street, Suite 1200, Sacramento, CA 95815-5401. It is advisable to keep a copy of the submitted form for your records.
Filling out the California FNP 004 form can be straightforward, but many individuals make common mistakes that can lead to delays or complications. One frequent error is not providing a complete current physical practice address. The form specifically states that a PO Box is not acceptable. Ensure that the address listed is accurate and reflects the actual location of your practice.
Another mistake involves the failure to include the correct FNP number. This number is essential for identifying your permit. Omitting it can result in processing delays or even rejection of your application. Double-check that this information is filled out correctly.
People often overlook the requirement to indicate their business structure. Whether you are a corporation, partnership, or sole proprietor must be clearly marked. Not specifying this can lead to confusion and potential legal issues down the line.
In addition, many applicants forget to provide their signature at the bottom of the form. This signature is crucial for validating the information provided. Without it, the form may be considered incomplete, and your request could be denied.
Another common error is failing to declare any changes in ownership accurately. If there are new shareholders or partners, this information must be updated in the designated table. Not doing so can result in complications regarding the legal standing of your practice.
Some individuals neglect to read the accompanying instructions thoroughly. The form references an attachment for current owners, which is vital for ensuring that all necessary parties are accounted for. Missing this step can lead to misunderstandings and delays.
Also, individuals sometimes miscalculate the renewal fee. Ensure that you check the current fee schedule and include the correct amount. An incorrect fee can stall the renewal process, leading to lapses in your permit.
People often fail to declare their license number correctly. This number is crucial for verifying your credentials. If it is missing or incorrect, it can cause significant delays in processing your application.
Lastly, applicants sometimes forget to keep a copy of the completed form for their records. This oversight can lead to confusion later, especially if questions arise about what was submitted.
By avoiding these common mistakes, you can streamline the process of renewing your fictitious name permit and ensure that your practice continues to operate smoothly.
The California FNP 004 form is used for notifying the Medical Board of California about changes related to a fictitious name permit. When dealing with fictitious name permits, several other forms and documents may be required to ensure compliance with state regulations. Below is a list of documents often associated with the FNP 004 form, along with a brief description of each.
Understanding these associated documents can help ensure that all necessary steps are taken when managing a fictitious name permit in California. Properly completing and submitting these forms will aid in maintaining compliance with state regulations and protecting the interests of the medical practice.
The California FNP 004 form, used for fictitious name permit notifications, shares similarities with several other documents related to business and medical practice regulations. Here are eight documents that are comparable:
When filling out the California FNP 004 form, it's important to follow certain guidelines to ensure accuracy and compliance. Here are five things you should and shouldn't do:
Understanding the California FNP 004 form is crucial for healthcare professionals. Here are ten common misconceptions about this form:
Being informed about these misconceptions can help ensure compliance and smooth operations in your medical practice.
When filling out and using the California FNP 004 form, consider the following key takeaways: