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It provides completion instructions, requires submission of supporting documents such as state medical license, DEA certificate, board certification, ECFMG certificate when applicable, and professional liability face sheet. The form gathers physician identifiers, demographics, intent to serve, specialty information, and comprehensive practice locations, contact information, office accessibility, languages, and billing arrangements across primary, secondary, and tertiary offices.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/california-participating-physician-application-application-instructions/277722/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/california-participating-physician-application-application-instructions/277722.png","ImageObject",442,249,{"name":88,"@type":89},"นรินทร์","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-15",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",9,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What supporting documents must be submitted with the California Participating Physician Application?","Question",{"text":109,"@type":110},"The instructions require current copies of the state medical license, DEA certificate, board certification (if applicable), ECFMG certificate (if applicable), and a face sheet of professional liability certification.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Which physician details are collected in the Case Information section?",{"text":114,"@type":110},"The form requests name variations, home address, phone and email (mandatory), birthdate and citizenship, birthplace, Social Security number, gender, race/ethnicity (voluntary), driver’s license details, and the physician’s intent to serve with specialty and subspecialties.",{"name":116,"@type":107,"acceptedAnswer":117},"How does the application collect practice and billing information?",{"text":118,"@type":110},"Practice Information captures office addresses, contact details, languages, physical accessibility, and operating hours for primary, secondary, and tertiary offices when applicable. Billing Information identifies which practice handles billing and includes billing company details such as contact person, address, and federal tax ID information.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},277722,1789503422,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":136,"language":137,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":61,"update_tm":126,"read_time":141},2336475104957,"https://ap-avatar.wpscdn.com/avatar/22000c4c6bd8a5076e1?x-image-process=image/resize,m_fixed,w_180,h_180&k=1787554080175789136","CONFIDENTIAL/PROPRIETARY  \nCalifornia Participating Physician Application  \nThis application is submitted to Vivant Health , herein, this Healthcare Organization.1  \n\n| I. INSTRUCTIONS |  |  |  |\n| --- | --- | --- | --- |\n| If more space is needed than provided on this application, attach additional sheets and reference the question being answered. Please do not use abbreviations when completing the application. Personal email addresses and phone numbers will not be used for any purpose other than contact between Vivant Health and the provider. Current copies of the following documents must be submitted with the application:\u003Cbr> State Medical License  Face Sheet of Professional Liability Certification\u003Cbr> DEA Certificate  Curriculum Vitae\u003Cbr> Board Certification (if applicable)  ECFMG Certificate (if applicable) |  |  |  |\n| II. CASE INFORMATION |  |  |  |\n| Last name: | First: |  | Middle: |\n| Is there any other name under which you have been known? Name(s): |  |  |  |\n| Home mailing street address: | City: |  |  |\n|  | State: |  | ZIP code: |\n| Home telephone number: | Email address (mandatory): |  |  |\n| Home fax number: | Pager/cell phone number (mandatory): |  |  |\n| Birthdate: | Citizenship (if not a United States citizen, please include copy of alien registration card): |  |  |\n| Birthplace (city/state/country): |  |  |  |\n| Social Security \\#: | Gender:2\u003Cbr>􀂆 Male\u003Cbr>􀂆 Female | Race/ethnicity (voluntary): |  |\n| Driver’s license state/ number: |  |  |  |\n| Your intent is to serve as a(n): 􀂆 Primary care provider 􀂆 Specialist 􀂆 Urgent Care 􀂆 Hospitalist 􀂆 Hospital based |  |  |  |\n| Specialty: |  |  |  |\n| Subspecialties: |  |  |  |\n| III. PRACTICE INFORMATION |  |  |  |\n| Practice name (if applicable): | Department name (if hospital based): |  |  |\n| Primary office street address: | City: |  |  |\n\n1As used in the Information Release/Acknowledgements Section of this application, the term “this Healthcare Organization” shall refer to the entity to  \nwhich this application is submitted as identified above.  \n2 This information will be used for consumer information purposes only.  \nCalifornia Participating Physician Application – 6/14  \nPhysician name:     \n1  \n24559-19 9/24  \nVivant Health | P.O. Box 15470, Sacramento, CA 95851 | (916) 228-4300  \nCONFIDENTIAL/PROPRIETARY  \n\n| Website (if applicable): | State: | ZIP code: |\n| --- | --- | --- |\n| Telephone number: | Fax number: |  |\n| Office manager/administrator: | Telephone number: |  |\n| Email address: | Fax number: |  |\n| Name affiliated with tax ID number: | Federal tax ID number: 􀂆 Same as above: |  |\n| Type of practice (check all that apply): 􀂆 Solo practice\u003Cbr>􀂆 Group practice 􀂆 Single-specialty group\u003Cbr>􀂆 Multispecialty group | Group NPI \\#: |  |\n| Primary office hours of operation:\u003Cbr>Monday: Tuesday:\u003Cbr>Wednesday: Thursday:\u003Cbr>Friday: Saturday:\u003Cbr>Sunday: | Group medicare PTAN/UPIN \\#: |  |\n| Languages spoken by provider: | Languages spoken by staff: |  |\n| Please identify the physical accessibility of this office: 􀂆 Basic 􀂆 Limited 􀂆 None |  |  |\n| Secondary office street address: | City: |  |\n|  | State: | ZIP code: |\n| Telephone number: | Fax number: |  |\n| Office manager/administrator: | Telephone number: |  |\n| Email address: | Fax number: |  |\n| Name affiliated with tax ID number: | Federal tax ID number: 􀂆 same as above |  |\n| Type of practice (check all that apply): 􀂆 Solo practice\u003Cbr>􀂆 Group practice 􀂆 Single-specialty group\u003Cbr>􀂆 Multispecialty group | Group NPI \\#: |  |\n| Secondary office hours of operation:\u003Cbr>Monday: Tuesday:\u003Cbr>Wednesday: Thursday:\u003Cbr>Friday: Saturday:\u003Cbr>Sunday: | Group medicare PTAN/UPIN \\#: |  |\n| Languages spoken by provider: | Languages spoken by staff: |  |\n| Please identify the physical accessibility of this office: 􀂆 Basic 􀂆 Limited 􀂆 None |  |  |\n\n2  \nCalifornia Participating Physician Application – 6/14  \nPhysician name:     \nCONFIDENTIAL/PROPRIETARY  \n\n| Tertiary office street address: | City: |  |\n| --- | --- | --- |\n|  |","cbCaioWn03cNufBW","https://ap.wps.com/l/cbCaioWn03cNufBW","pdf",482632,23,"English","# Instructions\n# Case Information\n# Practice Information\n# Billing Information\n# Practice Description","[{\"question\":\"What supporting documents must be submitted with the California Participating Physician Application?\",\"answer\":\"The instructions require current copies of the state medical license, DEA certificate, board certification (if applicable), ECFMG certificate (if applicable), and a face sheet of professional liability certification.\"},{\"question\":\"Which physician details are collected in the Case Information section?\",\"answer\":\"The form requests name variations, home address, phone and email (mandatory), birthdate and citizenship, birthplace, Social Security number, gender, race/ethnicity (voluntary), driver’s license details, and the physician’s intent to serve with specialty and subspecialties.\"},{\"question\":\"How does the application collect practice and billing information?\",\"answer\":\"Practice Information captures office addresses, contact details, languages, physical accessibility, and operating hours for primary, secondary, and tertiary offices when applicable. Billing Information identifies which practice handles billing and includes billing company details such as contact person, address, and federal tax ID information.\"}]","California Participating Physician Application - Application Instructions | PDF",8]