Get California Participating Physician Form

The California Participating Physician form is a crucial document for healthcare providers seeking to join health plans and medical groups in California. This form gathers essential information about a physician's practice, including their specialties, billing details, and office hours. If you're ready to take the next step in your medical career, fill out the form by clicking the button below.

Structure

The California Participating Physician form is a crucial document for healthcare providers seeking to join a health plan or medical group in California. This form collects essential information about the physician, including their identifying details, practice type, and billing information. It also requires physicians to disclose their affiliations with medical groups or independent practice associations (IPAs) and whether they plan to serve as primary care providers or specialists. Additional sections address the practice's operational aspects, such as office hours, coverage of practice, and any allied health professionals employed. Physicians must also provide information on laboratory services and any relevant accreditations or certifications. By completing this form, physicians ensure compliance with health plan requirements while facilitating a streamlined process for patient care and insurance reimbursement.

California Participating Physician Preview

License Number:

Type of Provider:

CONFIDENTIAL/PROPRIETARY

California Participating Physician Application

ADDENDUM A

Health Plans and IPA’s/Medical Groups

This Addendum is submitted to:		herein, this Healthcare Organization. 1

	I. IDENTIFYING INFORMATION

	Last Name:		First:		Middle:

	Medical Group (s) /IPA(s) Affiliation:

	Do you intend to serve as a primary care provider?		Yes	No
	Do you intend to serve as a specialist?		Yes	No (If yes, please list specialty(s))

Please check all that apply:

Solo Practice Group Practice

Single Specialty Multi specialty

II. BILLING INFORMATION

Billing Company:

Street Address:	City:

	State:		ZIP:

Contact:	Telephone Number: (	)

Name Affiliated with Tax ID Number:	Federal Tax ID Number:

III. PRACTICE INFORMATION

Do you employ any allied health professionals (e.g. nurse practitioners, physician assistants, psychologists, etc.)? No

If so, please list:

Name:

Yes

If you are a Physician Assistant Supervisor, please include State License Number:

Do you		personally employ any physicians (do not include physicians that are employed by the medical group)?
	No
If so, please list:
Name:			California Medical License Number:
	__			__
	__			__

Yes

The term “this Healthcare Organization” shall refer to the entity to which this Addendum is submitted as identified above.

California Participating Physician Application Addendum A - 05/97	Page 1 of 3
Physician Name:

Please list any clinical services you perform that are not typically associated with your specialty:

Please list any clinical services you do not perform that are typically associated with your specialty:

Is your practice limited to certain ages?

Yes

If yes, specify limitations:

Are you a Certified Qualified Medical Examiner (QME) of the State Industrial Medical Council?

Yes

Do you participate in EDI (electronic data interchange)?

Yes

If so, which Network?

Do you use a practice management system/software:

Yes

If so, which one?

What type of anesthesia do you provide in your group/office?

Local

Regional

Conscious Sedation

General

None

Other (please specify)

Has your office received any of the following accreditations, certifications or licensures?

American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)

California Department of Health Services Licensure

Institute for Medical Quality-Accreditation Association for Ambulatory Health Care (IMQ-AAAHC)

Medicare Certification

The Medical Quality Commission (TMQC)

Other

IV. OFFICE HOURS- Please indicate the hours your office is open:

Monday	Tuesday	Wednesday	Thursday	Friday

Saturday

Sunday

Holidays

V.COVERAGE OF PRACTICE (List your answering service and covering physicians by name. Attach additional sheets if necessary)

Answering Service Company:	Phone Number: (		)		Fax Number: (		)

Mailing Address:		City:

		State:				ZIP:

Covering Physician's Name:		Telephone Number:		(	)

Covering Physician's Name:		Telephone Number:		(	)

Covering Physician's Name:		Telephone Number:		(	)

Covering Physician's Name:		Telephone Number:		(	)

If you do not have hospital privileges, please provide written plan for continuity of care:

California Participating Physician Application Addendum A - 05/97	Page 2 of 3
Physician Name:

California Participating Physician Application Addendum A - 05/97	Page 3 of 3
Physician Name:

VI. FOREIGN LANGUAGES SPOKEN

Fluently by Physician:

Fluently by Staff:

VII. LABORATORY SERVICES

If you provide direct laboratory services, please indicate the TIN utilized and provide Clinical Laboratory Information Act (CLIA) information. Attach a copy of your CLIA certificate or waiver if you have one.

Tax ID #:	Billing Name:	Type of Service Provided:

Do you have a CLIA certificate?	Yes	No

Do you have a CLIA waiver?	Yes	No

Certificate Number:		Certificate Expiration Date:

VIII. PROFESSIONAL ORGANIZATIONS

Please list country, state or national medical societies, or other professional organizations or societies of which you are a member or applicant.

Organization Name

Applicant

Member

I certify that the information in this document and any attached documents is true and correct.

Print Name Here: _____________________________________________________________________________

Physician Signature: _______________________________________________________________________Date:

(Stamped Signature Is Not Acceptable)

California Participating Physician Application Addendum A - 05/97	Page 4 of 3
Physician Name:

➤ PDF File

Document Data

Fact Name	Description
License Requirement	The California Participating Physician form requires a valid California Medical License Number for all participating physicians.
Confidentiality	This form is marked as CONFIDENTIAL/PROPRIETARY, ensuring that the information provided is protected.
Billing Information	Physicians must provide detailed billing information, including the name of the billing company and Federal Tax ID Number.
Governing Laws	The form is governed by California Health and Safety Code Section 1200, which outlines the requirements for physician participation in health plans.

How to Use California Participating Physician

Completing the California Participating Physician form requires attention to detail and accurate information. Follow these steps to ensure that all necessary sections are filled out correctly.

Begin with the Identifying Information section. Enter your last name, first name, and middle name. Include your medical group or IPA affiliation. Indicate whether you intend to serve as a primary care provider or a specialist, and if applicable, list your specialties. Select the practice type that applies to you.
Proceed to the Billing Information section. Fill in the name of your billing company, street address, city, state, and ZIP code. Provide a contact name and telephone number. Include the name affiliated with your Tax ID number and your Federal Tax ID number.
In the Practice Information section, indicate if you employ any allied health professionals or physicians. If yes, list their names and provide your California Medical License Number if applicable. Answer questions regarding clinical services, age limitations, and certifications.
Next, fill out the Office Hours section. Specify the hours your office is open for each day of the week.
For the Coverage of Practice section, list your answering service company, phone number, and fax number. Include the names and telephone numbers of covering physicians.
Complete the Foreign Languages Spoken section by indicating which languages are spoken fluently by you and your staff.
In the Laboratory Services section, provide your Tax ID number, billing name, and type of service provided. Indicate whether you have a CLIA certificate or waiver, and include the certificate number and expiration date if applicable.
List any professional organizations you belong to in the Professional Organizations section. Specify if you are an applicant or a member of each organization.
Finally, certify the accuracy of the information by printing your name and signing the document. Ensure that the signature is original, as stamped signatures are not acceptable.

Key Facts about California Participating Physician

What is the purpose of the California Participating Physician form?

The California Participating Physician form is designed to collect essential information from physicians who wish to participate in a healthcare organization, such as a medical group or health plan. It gathers details about the physician's practice, specialties, billing information, and any additional services they may provide. This information helps healthcare organizations assess the qualifications and capabilities of the physicians applying to join their network.

What information is required on the form?

The form requires various pieces of identifying information, including the physician's name, medical license number, and affiliations with medical groups or IPAs. Additionally, it asks about the type of practice, billing details, and any allied health professionals employed. Physicians must also provide information about their specialties, office hours, and any laboratory services offered. This comprehensive data ensures that the healthcare organization has a clear understanding of the physician's practice.

How do I submit the California Participating Physician form?

To submit the form, physicians should complete all required sections and ensure that the information is accurate and up-to-date. After filling out the form, it should be sent to the healthcare organization or medical group to which the physician is applying. The specific submission method may vary by organization, so it is advisable to check their guidelines for any particular requirements or preferred submission formats.

Can I update my information after submitting the form?

Yes, physicians can update their information after submission. If there are changes in practice details, specialties, or contact information, it is important to notify the healthcare organization promptly. This ensures that the organization maintains accurate records and can effectively communicate with the physician regarding any necessary updates or changes in their status within the network.

What happens if I do not provide all the requested information?

Failure to provide all requested information may result in delays in processing the application or even denial of participation. Healthcare organizations rely on complete and accurate information to evaluate each physician's qualifications. It is crucial to review the form thoroughly before submission to ensure that all sections are completed and all necessary documentation is attached.

Is the information provided in the form confidential?

Yes, the information provided in the California Participating Physician form is considered confidential and proprietary. Healthcare organizations are required to protect this information and use it solely for the purpose of evaluating the physician's application. However, physicians should be aware that certain information may be shared with relevant parties as part of the credentialing process.

Common mistakes

Filling out the California Participating Physician form can seem straightforward, but there are common mistakes that can lead to delays or complications in the application process. Understanding these pitfalls can help ensure a smoother experience.

One frequent mistake is failing to provide complete identifying information. Applicants sometimes forget to include their full names or leave out their middle names. This can lead to confusion and may delay the processing of the application. It’s essential to double-check that all required fields are filled out accurately, including the medical group or IPA affiliations.

Another common error is neglecting to specify whether the physician intends to serve as a primary care provider or a specialist. This section is crucial for the healthcare organization to understand the applicant's role. If left unchecked or incorrectly marked, it could result in miscommunication about the physician's qualifications and intended practice.

Billing information is often overlooked. Some applicants fail to include the correct billing company name or contact details. Providing accurate billing information is vital for insurance purposes and can prevent future billing issues. Ensure that the contact number is correct and that the tax identification numbers are accurate as well.

Many applicants also forget to list the clinical services they perform that are not typically associated with their specialty. This omission can limit the understanding of the physician's capabilities. Conversely, failing to mention clinical services that are typically associated with their specialty can lead to misunderstandings about their qualifications.

Another mistake involves the section regarding office hours. Some applicants either leave this blank or provide incomplete information. Clearly indicating office hours is essential for patient scheduling and for the healthcare organization to understand the physician's availability.

Lastly, applicants sometimes overlook the requirement for signatures. A stamped signature is not acceptable, and failing to sign the document can lead to immediate rejection of the application. It’s important to review the document carefully to ensure that all necessary signatures are included before submission.

By being mindful of these common mistakes, physicians can improve their chances of a successful application process. Taking the time to review each section thoroughly can make a significant difference in the outcome.

Documents used along the form

The California Participating Physician form is essential for healthcare providers looking to join a network of participating physicians. However, several other documents are often used in conjunction with this form to ensure a comprehensive application process. Below is a list of these documents, each serving a specific purpose in the overall application and credentialing procedure.

Credentialing Application: This document collects detailed information about a physician's education, training, work history, and qualifications. It is a crucial part of verifying a physician's credentials before they can practice within a network.
Malpractice Insurance Certificate: This certificate proves that a physician has valid malpractice insurance. It protects both the physician and the healthcare organization from potential legal claims.
California Medical License: A copy of the physician's valid California medical license is required to confirm that they are legally authorized to practice medicine in the state.
DEA Registration Certificate: This document is necessary for physicians who prescribe controlled substances. It verifies that the physician is registered with the Drug Enforcement Administration.
Tax Identification Number (TIN): The TIN is used for tax purposes and is essential for billing and insurance claims. It identifies the physician or practice for tax reporting.
Curriculum Vitae (CV): A CV provides a comprehensive overview of a physician's professional background, including education, work experience, and publications. It helps assess their qualifications and expertise.
Board Certification Documentation: Proof of board certification in a medical specialty demonstrates a physician's advanced training and expertise in that area.
Continuity of Care Plan: This plan outlines how a physician will ensure patient care continuity, especially if they do not have hospital privileges. It is vital for maintaining quality care.
References: Letters of recommendation from other healthcare professionals or institutions can support a physician's application by vouching for their skills and character.
Language Proficiency Certification: If applicable, this document verifies a physician's proficiency in languages other than English, which can be crucial for serving diverse patient populations.

Each of these documents plays a significant role in the application process for the California Participating Physician form. Together, they create a complete picture of a physician’s qualifications, ensuring that they meet the necessary standards to provide quality care within the network.

Similar forms

The California Participating Physician form shares similarities with several other important documents in the healthcare sector. Each of these documents serves a unique purpose but includes common elements such as identifying information, practice details, and professional affiliations. Below is a list of six documents that are similar to the California Participating Physician form:

Provider Enrollment Form: This document collects essential information about healthcare providers, including their qualifications and practice details. It also requires disclosure of any affiliations with medical groups or health plans, similar to the California form.
Credentialing Application: Used by hospitals and health plans, this application verifies a provider’s qualifications, including education, training, and professional experience. Like the California form, it gathers information on specialties and practice settings.
Medicare Enrollment Application (CMS-855I): This form is specifically for enrolling in Medicare as an individual provider. It requires similar identifying information, including medical license details and practice information, paralleling the structure of the California Participating Physician form.
Insurance Provider Application: This application is necessary for healthcare providers seeking to join insurance networks. It requests information about the provider's practice, specialties, and any affiliations, akin to the California form’s requirements.
State Medical Board Application: This application is used for obtaining or renewing a medical license. It includes sections for personal and professional information, which mirrors the California Participating Physician form's focus on identifying information and practice details.
Continuity of Care Plan: This document outlines how a provider will ensure patient care continuity in the absence of direct hospital privileges. It shares the need for detailed practice information and coverage plans, similar to the coverage of practice section in the California form.

Dos and Don'ts

When completing the California Participating Physician form, it is important to follow specific guidelines to ensure accuracy and compliance. Below is a list of recommended actions and pitfalls to avoid.

Do provide complete and accurate identifying information, including your full name and medical group affiliations.
Do indicate whether you intend to serve as a primary care provider or specialist, and specify your specialties if applicable.
Do include all relevant billing information, ensuring that the Tax ID numbers are correct.
Do disclose any allied health professionals you employ, as well as any clinical services you perform that are not typical for your specialty.
Do ensure your signature is original, as stamped signatures will not be accepted.

Don't leave any sections blank; incomplete forms can lead to delays in processing.
Don't provide false or misleading information, as this can result in penalties or disqualification.
Don't forget to attach necessary documentation, such as your CLIA certificate, if applicable.
Don't overlook the importance of listing your office hours and coverage plans accurately.
Don't neglect to specify any limitations regarding the ages of patients you will serve.

Misconceptions

Understanding the California Participating Physician form is crucial for healthcare providers navigating the state's medical landscape. Unfortunately, several misconceptions can lead to confusion. Here are five common misconceptions clarified:

The form is only for primary care providers. Many believe that the California Participating Physician form is exclusively for primary care providers. In reality, it is applicable to both primary care and specialist physicians.
Submitting the form guarantees participation in health plans. Some providers think that simply submitting the form ensures they will be accepted by health plans. Acceptance depends on various factors, including the provider's qualifications and the specific health plan's requirements.
All information provided is public. There is a misconception that the details submitted in the form are public records. However, the form is marked as confidential and proprietary, meaning that personal information is protected.
Only California-licensed physicians need to fill out the form. While it is true that California-licensed physicians must complete the form, out-of-state physicians seeking to practice in California may also need to submit it as part of their application process.
Completing the form is a one-time requirement. Many believe that once the form is submitted, no further action is needed. In fact, physicians must keep their information updated and may need to resubmit the form periodically to maintain their participation status.

Addressing these misconceptions can help ensure that healthcare providers navigate the application process more effectively and understand their obligations and rights within the California medical system.

Key takeaways

Filling out the California Participating Physician form can seem daunting, but understanding its components can simplify the process. Here are some key takeaways to keep in mind:

Personal Information: Ensure that all identifying information, such as your name and medical group affiliations, is accurate and complete.
Provider Type: Clearly indicate whether you will serve as a primary care provider or a specialist, and specify your specialties if applicable.
Billing Details: Include your billing company information, including the address and contact details, to facilitate accurate billing processes.
Practice Information: Note whether you employ allied health professionals or other physicians, as this can impact your practice's operations and billing.
Clinical Services: Be transparent about the clinical services you provide, especially those not typically associated with your specialty.
Accreditations: List any relevant accreditations or certifications your practice has received, as these can enhance your credibility.
Office Hours: Clearly state your office hours to ensure patients know when they can reach you.
Continuity of Care: If you lack hospital privileges, provide a written plan detailing how you will ensure continuity of care for your patients.
Certification: Remember to sign the form, certifying that all information provided is true and correct; a stamped signature is not acceptable.

By following these guidelines, you can effectively navigate the California Participating Physician form, ensuring compliance and a smoother process for your practice.