Adobe Acrobat Version
Allied Health, Healthplan Enrollment

The Adobe Acrobat version is the recommended for initiating the enrollment process, as there are fewer steps to submission.

However, some Mac users or users with an early version of Adobe Acrobat on their computer may have problems using the Adobe Acrobat application. For those users the below Word version of the enrollment applications is also available.

Step 1:
Prior to health plan enrollment each UCSF provider is now required to procure a National Provider Identifier. An NPI is required for health plan enrolment.
    *      Apply online for your NPI here   *Learn more about NPI's*

Step 2:
Complete Allied Health, Healthplan Enrollment
Email forms using "Submit" button in the electronic application

Step 3:
      Print out & complete signature pages large file allow time for download
      Complete two (2) page Brown & Toland application
      Sign all signature pages where noted in the left hand columns.

Step 4:
Forward everything to your department contact INCLUDING:
    *3 page application and 11 signature pages
-- Including Medi-Cal signature page of your supervising MD --
      With original signatures and Brown & Toland application completed
      Legible photocopies of your
    *      California Professional License
    *      Curriculum Vitae (CV)
    *      Photo ID (passport, driver’s license)
    *      Masters Degree (NP's)
    *      Supervising MD's California Medical License
    *      Supervising MD's photo ID (passport, driver's license)
    *      Printed email confirmation of your NPI
    *      National Certification (all that apply, RN, NP, PA...)

Adobe Acrobat Challeneged? No worries, try using the ©Microsoft Word version found here instead!