For your organization, you will need:

• legal name of the organization
• mailing address

For the person signing the DSA, you will need:

• name
• title within the organization
• phone number
• email address

If your organization does not have subordinate entities or facilities, in addition to other information for your organization you will need:

• type of organization, one of:
  • general acute care hospital
  • physician organization or medical group
  • health care service plan or disability insurer, including risk-based organizations, Medi-Cal managed care plan services, and other health care service plans or disability insurers
  • skilled nursing facility
  • clinical laboratory
  • acute psychiatric hospital
  • other, voluntary signatory

How do I know if what type of organization I am?

• California license number for general acute care hospitals, health care service plans or disability insurers, skilled nursing facilities, clinical laboratories, or acute psychiatric hospitals.

How do I know which license number to use?

• Employer Identification Number (EIN) for physician organizations, medical groups, or other, voluntary signatories.

If you don’t have an EIN, you can apply for an EIN online.

If your organization has subordinate entitles or facilities for which the individual would like to sign, you will need the following for each subordinate organization:

• legal name
• mailing address
• type of subordinate entity or facility, as described above in the information you will need for your organization
• California license number or EIN, as described above in the information you will need for your organization

What is a subordinate organization?

If your organization or one of your subordinate entities or facilities has multiple license numbers for multiple organization types (e.g., a licensed general acute care hospital with a licensed clinical laboratory), they should be listed separately as separate subordinate entities using the appropriate legal name, organization type, and license number or EIN.