Applications for Licensing and/or Certification of a Primary Care Clinic
The following forms and documents are required for licensure and/or certification.
A Clinic Exemption list can be found here
(After clicking link, please click first search result, then scroll to Section 1206).
How to apply for specified health programs simultaneously:
To learn about the process and obtain the forms to simultaneously apply for the following health programs as you apply for a clinic license, please reference the sites and documents below.
In addition to the forms below, you are required to submit additional documents for a change of ownership and for a Mobile Clinic. These documents must be submitted with your completed application. The required information and instructions are listed on the checklist contained in the Primary Care Clinic Facility Application Request Letter and Instructional Checklist (PDF)letter.
For an Affiliate Primary Care Clinic, the required information and instructions are listed on a separate checklist contained in the Affiliate Primary Care Clinic Facility Application Request Letter and Instructional Checklist (PDF) letter.
Primary Care Clinic - Community or Free Clinic (Including Mobile Clinic)
Required Forms to be Licensed:
Required Forms to be Certified with Medicaid/Medi-Cal: