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.

• Medi-Cal Presumptive Eligibility for Pregnant Women (PE)
• Child Health and Disability Prevention (CHDP) Program
• Comprehensive Perinatal Services Program (CPSP):  CDPH 4448 (PDF)
• Family Planning, Access, Care, and Treatment (Family PACT):  CDPH 4468 (PDF)

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:

• Licensure & Certification Application:  HS 200 
  Title 24 Building Requirements: In lieu of a letter from a licensed architect, the licensed architect may use the attached form, “Certification Form For Clinics and Freestanding Outpatient Clinic Services of A Hospital”. (PDF)
• Applicant Individual Information:  HS 215A (PDF)
• Administrative Organization:  HS 309 (PDF)
• Transfer Agreement Between:  HS 602 (PDF)
• Fire Safety Inspection Request:  STD 850 (PDF)
• Civil Rights Compliance Review (Title VI, Section 504, ADA):  DHCS 1051 (PDF)

Required Forms to be Certified with Medicaid/Medi-Cal:

• Application for Medi-Cal Certification as a Primary Care Clinic Provider:  HS 269 (PDF)
• Notice - Effective Date of Provider Agreement:  HS 328 (PDF)
• Medi-Cal Provider Agreement:  DHCS 9098 (PDF)