The California FNP 004 form serves as a notification for the renewal or hold release of a fictitious name permit in the medical field. This form is crucial for medical practitioners operating under a fictitious name, ensuring compliance with state regulations. To maintain your practice's legitimacy, it is essential to complete and submit this form accurately; get started by clicking the button below.
The California FNP 004 form plays a crucial role in the regulation of medical practices within the state. It serves as a notification for the renewal or hold release of a fictitious name permit, which is essential for healthcare providers operating under a name different from their legal business name. This form requires specific information, including the fictitious name, current physical practice address, and the license number of the healthcare provider. It also demands details about the business structure—whether it’s a corporation, partnership, or sole proprietorship. Notably, the form emphasizes that fictitious name permits are non-transferable; thus, if a medical practice changes ownership, both the former and new owners must complete separate applications to ensure compliance. Additionally, any changes in shareholders or partners must be documented, necessitating signatures for both association and disassociation. Completing the FNP 004 form accurately is not just a matter of legal compliance; it is also vital for maintaining the integrity and continuity of medical services provided to the community. By adhering to these requirements, healthcare professionals can ensure that they are operating within the bounds of California law while safeguarding their practice's reputation.
MEDICAL BOARD
Sacramento, CA 95815-5401
Licensing Program
2005 Evergreen Street, Suite 1200
O F C A L I F O R N I A
Phone: (916)
263-2382
Fax: (916)
263-2487
Protecting consumers by advancing high quality, safe medical care.
www.mbc.ca.gov
Gavin Newsom, Governor, State of California | Business, Consumer Services and Housing Agency | Department of Consumer Affairs
FICTITIOUS NAME PERMIT
NOTIFICATION OF RENEWAL/HOLD RELEASE
Fictitious Name:
Current Physical
Practice Address:
(No PO Box)
Our records indicate that you are presently doing business as:
FNP #:
SS#/FEIN#:
Phone #:
Renewal Fee: $
Corporation
Partnership
Individual (Sole Proprietor)
A hold has has not been placed on your Fictitious Name Permit. In order for the hold to be removed, this form must be completed in its entirety and signed by a current owner. Refer to the enclosed attachment indicating the current owner(s). Note: A fictitious name permit is not transferable. If a medical practice is purchased by another physician, the
former owner must submit an “Application for Cancellation of a Fictitious Name Permit” to cancel the permit and the new owner must submit a “Fictitious Name Permit Application.” Both forms should be mailed at the same time to assure the name will be available to the new owner.
If you are doing business as a corporation or as a partnership and wish to add/delete shareholders or partners, please provide the following information in the table below. Signatures are required to associate or disassociate shareholders or partners. A signature at the bottom of this form also is required to change the address or renew the permit. Refer to attachment for current owners.
Doctor’s Name (print or type)
License #
Association
Disassociation
Signature
Date
..
+
I declare under penalty of perjury under the laws of the State of California that I have read the foregoing notification and all attachments thereto and know the contents thereof. I have the legal authority to act on behalf of the above-stated entity and the information contained herein is true and correct.
________________________________
______________________________
_____________
____________
Print or Type Name
FNP-004 (Revised 01/2019)
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