Get the free california participating physician application form

Name: California Participating Physician Application - Fill Online, Printable, Fillable, Blank, Sign | pdfFiller
Brand: pdfFiller
Rating: 4.9 (59 reviews)

Get Form

Show details

CONFIDENTIAL/PROPRIETARY California Participating Physician Reapplication This application is submitted to herein this Healthcare Organization1 I. Addenda Submitting Please check the following Addendum A - Health Plan and IPA/Medical Group Addendum B - Professional Liability Action Explanation endorsed by American Medical Group Association - 703/838-0033 x325 California Association of Health Plans - 916/552-2910 California Healthcare Association - 916/552-7574 California Medical Association -...

pdfFiller is not affiliated with any government organization

Get, Create, Make and Sign

Edit your california participating physician application form online

Type text, complete fillable fields, insert images, highlight or blackout data for discretion, add comments, and more.

Add your legally-binding signature

Draw or type your signature, upload a signature image, or capture it with your digital camera.

Share your form instantly

Email, fax, or share your california participating physician application form via URL. You can also download, print, or export forms to your preferred cloud storage service.

How to edit california participating physician application online

Ease of Setup

pdfFiller User Ratings on G2

Ease of Use

pdfFiller User Ratings on G2

Here are the steps you need to follow to get started with our professional PDF editor:

1

Log in. Click Start Free Trial and create a profile if necessary.

2

Upload a file. Select Add New on your Dashboard and upload a file from your device or import it from the cloud, online, or internal mail. Then click Edit.

3

Edit cppa application form. Rearrange and rotate pages, insert new and alter existing texts, add new objects, and take advantage of other helpful tools. Click Done to apply changes and return to your Dashboard. Go to the Documents tab to access merging, splitting, locking, or unlocking functions.

4

Save your file. Select it from your list of records. Then, move your cursor to the right toolbar and choose one of the exporting options. You can save it in multiple formats, download it as a PDF, send it by email, or store it in the cloud, among other things.

pdfFiller makes dealing with documents a breeze. Create an account to find out!

How to fill out california participating physician application

Question:

Write point by point how to fill out California participating physician reapplication. Who needs California participating physician reapplication?

How to fill out California participating physician reapplication:

01

Obtain the reapplication form from the California Medical Board website or request it by mail.

02

Carefully read all instructions provided on the form to ensure compliance with requirements.

03

Provide your personal information accurately, including name, contact details, and medical license number.

04

Complete the sections regarding your medical education, residency training, and any post-graduate training.

05

Provide information about your current or most recent medical practice, including the name and address of the medical facility.

06

Disclose any criminal convictions or disciplinary actions related to your medical practice as required.

07

Complete the "Professional History" section, detailing your medical employment history and any gaps in practice.

08

Fill out the "Malpractice/Judgment History" section if applicable, providing details of any malpractice claims or judgments against you.

09

Include any relevant professional memberships, certifications, or honors you have received in the appropriate section.

10

Review the completed reapplication form thoroughly, ensuring all information is accurate and all required sections are completed.

11

Attach any required supporting documentation, such as proof of completed continuing medical education or licensure renewal.

12

Sign and date the reapplication form, certifying that the information provided is true and accurate.

13

Submit the completed reapplication form and any supporting documents to the California Medical Board by mail or electronically, as instructed.

Who needs California participating physician reapplication:

01

Physicians who wish to continue practicing medicine in California and have previously participated in the California participating physician program.

02

Physicians whose participation in the program is expiring or has expired and need to renew their participation.

03

Physicians who may have had a lapse in participation or require reapplication due to disciplinary actions or other circumstances specified by the California Medical Board.

Who needs a physician reapplication?
What is a physician reapplication for?
Is it accompanied by other forms?

Who needs a physician reapplication?

This an essential document in the regular recredentialing process for practicing physicians in the State of California. They must fill it out upon request from the medical institution or another healthcare organization in order to prove professional competence and qualify for renewing a contract with this entity.

What is a physician reapplication for?

Re credentialing is usually held every three years, or when the initial contract between a physician and a healthcare organization is about to expire. Upon the due date, employer’s representative sends a request to the physician for filing this reapplication alongside several addenda regarding physician’s level of competence.

Is it accompanied by other forms?

There are 4 addenda to this application: State Medical License, DEA Certificate, Board Certification (if applicable) within last three years, Face Sheet of Professional Liability Certification. All copies must be up-to-date.

When is physician reapplication due?

This reapplication must be filed before the current contract between a physician and a healthcare institution expires. Physicians should not submit this reapplication, if they would not to change their job.

How do I fill out a physician reapplication?

Physicians are to furnish this application with identifying information, service information, residencies and fellowships, board certification and other certifications within the last three years, medical licensure/registration, other state medical licenses, professional liability, current hospital and other institutional affiliations. Also, there must be work history for the last three years. Another thing is a questionnaire with checkboxes called “Attestation questions”. Physicians must explain their answers in the checkboxes on a separate sheet of paper. In the end they must sign the Information Release Acknowledgements.

Where do I send it?

Reapplication must be submitted to the HR department of the healthcare organization hiring the physician.

Video instructions and help with filling out and completing california participating physician application

Instructions and Help about california participating physician reapplication form

Fill california physician reapplication : Try Risk Free

Rate free medical proof form

4.9

Satisfied

59 Votes

Our user reviews speak for themselves

Read more or give pdfFiller a try to experience the benefits for yourself

5

I think it's fantastic. Really helps us keep on track of our records

Anonymous Customer

5

I have not used PDFfiller very often as not needed. I hope to use it once more in the coming week.

Agnes M K

For pdfFiller’s FAQs

Below is a list of the most common customer questions. If you can’t find an answer to your question, please don’t hesitate to reach out to us.

What is california participating physician reapplication?

California Participating Physician Reapplication (CPPR) is a program designed to help healthcare providers in California maintain their participation in Medicare and Medi-Cal. The CPPR program helps healthcare providers in California with the reapplication process for Medicare and Medi-Cal, and allows them to receive reimbursement for medical services provided to Medicare and Medi-Cal beneficiaries. The CPPR program also helps providers stay compliant with Medicare and Medi-Cal regulations and policies.

How to fill out california participating physician reapplication?

1. Download the Participating Physician Reapplication form from the California Department of Health Care Services website. 2. Complete all applicable sections of the form, including the personal information and professional information sections. 3. Sign and date the form in the appropriate places. 4. Include a copy of your current license or certificate to practice in California. 5. Include a copy of any other documents or materials that may be requested by the Department of Health Care Services. 6. Submit the completed form, along with any required documents or materials, to the California Department of Health Care Services.

What is the purpose of california participating physician reapplication?

The California Participating Physician Reapplication is designed to enable physicians to update their information with the California Department of Managed Health Care (DMHC). Physicians must reapply every two years to remain on the DMHC's Participating Physician List, which is a list of physicians approved to provide services to enrollees in a health plan.

What information must be reported on california participating physician reapplication?

California Participating Physician Reapplication requires the following information: 1. Personal Information: Full name, address, telephone number, email address, Social Security Number (SSN), and date of birth. 2. Education: Medical school attended, year of graduation, postgraduate training, and specialty board certification. 3. Professional Information: Medical license number and status, DEA license number and status, NPI number, and California Medical Association (CMA) membership. 4. Contracting Information: Current contracting status with all managed care organizations (MCOs) and any requested changes. 5. Disclosure Information: Disclosure of any criminal or civil convictions, sanctions, or other corrective action taken by professional regulatory agencies, and any current or pending malpractice suits. 6. Financial Information: Acknowledgement of financial arrangements for the provision of medical services to MCOs and an affidavit of financial responsibility. 7. Attestation: A signed attestation that all information provided is accurate and current.

What is the penalty for the late filing of california participating physician reapplication?

The penalty for the late filing of a California Participating Physician Reapplication is a fine of up to $1,000 for each day the application is late.

Who is required to file california participating physician reapplication?

The California participating physician reapplication is required to be filed by physicians who are currently participating in the California Medical Assistance Program (Medi-Cal) and wish to continue participating in the program.

How can I edit california participating physician application from Google Drive?

pdfFiller and Google Docs can be used together to make your documents easier to work with and to make fillable forms right in your Google Drive. The integration will let you make, change, and sign documents, like cppa application form, without leaving Google Drive. Add pdfFiller's features to Google Drive, and you'll be able to do more with your paperwork on any internet-connected device.

Where do I find california participating physician reapplication?

The premium subscription for pdfFiller provides you with access to an extensive library of fillable forms (over 25M fillable templates) that you can download, fill out, print, and sign. You won’t have any trouble finding state-specific california current and other forms in the library. Find the template you need and customize it using advanced editing functionalities.

How do I complete california required online?

pdfFiller has made it simple to fill out and eSign medical proof form. The application has capabilities that allow you to modify and rearrange PDF content, add fillable fields, and eSign the document. Begin a free trial to discover all of the features of pdfFiller, the best document editing solution.

Fill out your california participating physician application online with pdfFiller!

pdfFiller is an end-to-end solution for managing, creating, and editing documents and forms in the cloud. Save time and hassle by preparing your tax forms online.

Get started now