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California participating ancillary 2026
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- Click ‘Get Form’ to open the California Participating Ancillary application in the editor.
- Begin by filling out the Identifying Information section. Enter your last name, first name, middle name, and any other names you may have used. Provide your home mailing address, telephone number, email address, and birth details.
- Move on to the Practice Information section. Input your practice name, department name (if applicable), and primary office address along with contact details.
- In the Medical/Nursing/Professional Education section, list your medical school and degree received. Include graduation dates and addresses as needed.
- Complete the Professional Licensure/Registrations section by entering your state medical license number and DEA registration details. Remember to attach copies of required documents.
- Fill out the Professional Liability section with your current insurance carrier information and policy details.
- Lastly, answer the Attestation Questions honestly. Ensure all information is accurate before submitting.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 1997 | 4.8 Satisfied (206 Votes) |
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