The California FNP 004 form is a notification form used for the renewal or hold release of a fictitious name permit. It is essential for medical practitioners operating under a fictitious name to ensure compliance with state regulations.
Any medical professional or entity currently doing business under a fictitious name in California must complete this form. This includes sole proprietors, partnerships, and corporations that wish to renew their fictitious name permit or address any changes in ownership.
The form requires several key pieces of information:
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Fictitious name
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Current physical practice address (no P.O. Box)
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FNP number
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Social Security Number (SSN) or Federal Employer Identification Number (FEIN)
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Contact phone number
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Details about the ownership structure (individual, partnership, corporation)
The renewal fee for the fictitious name permit is specified on the form. It is important to check the latest fee schedule as it may vary.
Can the fictitious name permit be transferred to another owner?
No, a fictitious name permit is not transferable. If a medical practice is sold, the former owner must cancel the permit, and the new owner must apply for a new fictitious name permit.
What should I do if I want to add or remove partners or shareholders?
If you are operating as a corporation or partnership and wish to add or remove partners or shareholders, you must provide the necessary information in the designated section of the form. Signatures are required for both association and disassociation.
What happens if there is a hold on my fictitious name permit?
If a hold has been placed on your fictitious name permit, you must complete the FNP 004 form in its entirety and have it signed by a current owner to remove the hold.
The declaration at the bottom of the form is a legal affirmation that the information provided is true and correct. By signing, the individual confirms they have the authority to act on behalf of the entity and acknowledges the penalties for false statements.
The completed form should be mailed to the Medical Board of California at the address provided on the form. Ensure that all required attachments are included to avoid processing delays.
You can reach the Medical Board of California by phone at (916) 263-2382 or by fax at (916) 263-2487. Additional information is also available on their website at www.mbc.ca.gov.