California participating 1 form 2025

1. Click ‘Get Form’ to open the California Participating Physician Application in the editor.
2. Begin by filling out the Identifying Information section. Enter your last name, first name, and middle name, along with your medical group or IPA affiliation. Indicate whether you intend to serve as a primary care provider or specialist by checking the appropriate boxes.
3. Proceed to the Billing Information section. Input your billing company details, including street address, city, state, ZIP code, and contact information. Ensure that you provide your Federal Tax ID Number accurately.
4. In the Practice Information section, answer questions regarding allied health professionals and any clinical services you perform. If applicable, list any physicians you employ and their details.
5. Complete the Office Hours section by indicating your office's operating hours for each day of the week.
6. Fill out the Coverage of Practice section with details about your answering service and covering physicians. Attach additional sheets if necessary.
7. Finally, review all sections for accuracy before signing and dating the document at the end.

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