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Health Facility

Licensing and Certification Application Letters and Checklists for:

Healthcare Professional

 

All Licensing and Certification Forms

 Form #
Form Title

BCIA 8016

 

 Request for Live Scan Service:

  • Sample Form for Licensee, Administrators, Adult Day Health Care, and Direct Care staff of ICFDD, ICFDDN, ICFDDH Facilities
  • Sample Form for certification of Nurse Assistants or Home Health Aids
  • Sample Form for Home Health Agency Licensee
  • CDPH 171

     

    40 Hour Home Health Aide (HHA) Training Program Application

    CDPH 171A

     

    40 Hour Home Health Aide (HHA) Training Program Current Curriculum

    CDPH 171B

     

    40 Hour Home Health Aide (HHA) Training Program Faculty Application

    CDPH 183

     

    Home Health Aide (HHA) Certification List

    CDPH 191

    120 HourHome Health Aide (HHA) Training Program Application

    CDPH 191A

     

    120 Hour Home Health Aide (HHA) Training Program Current Curriculum

    CDPH 191B

     

    120 Hour Home Health Aide (HHA) Training Program Faculty Information

    CDPH 192

    Application for Initial or Renewal as a Continuing Education Provider

    CDPH 192b

     

    Application for Initial or Renewal Online Continuing Education Provider

    CDPH 241

    Application for Cardiovascular Surgery Service

    CDPH 242

    Application for Chronic Dialysis Service

    CDPH 243

    Application for Dental Service

    CDPH 245

    Application for Nuclear Medicine Service

    CDPH 246

    Application for Outpatient Service

    CDPH 247

    Application for Pediatric Service

    CDPH 248

    Application for Perinatal Unit

    CDPH 249

    Application for Podiatric Service

    CDPH 250

    Application for Psychiatric Unit

    CDPH 251

    Application for Radiation Therapy Service

    CDPH 252

    Application for Renal Transplant Center

    CDPH 253

    Application for Respiratory Care Service

    CDPH 255

    Application for Social Service

    CDPH 256

    Application for Standby Emergency Medical Service, Physician on Call

    CDPH 257

    Application for Basic Emergency Medical Service, Physician on Duty

    CDPH 258

    Application for Comprehensive Emergency Medical Service

    CDPH 259

    Application for Rehabilitation Center

    CDPH 260

    Application for Occupational Therapy Service

    CDPH 261

    Application for Physical Therapy Service

    CDPH 262

    Application for Speech Pathology and/or Audiology Service

    CDPH 263

    Application for Acute Respiratory Care Service

    CDPH 264

    Application for Burn Center

    CDPH 265

    Application for Coronary Care Service

    CDPH 266 

    Application for Intensive Care Newborn Nursery Service

    CDPH 267

    Application for Intensive Care Service

    CDPH 268

    Application for Supplemental Services Approval

    CDPH 276 A

     

    Sample Form (Maybe us used by provider) Nursing Assistant Training Program Skills Checklist

    CDPH 276 B

     

    Daily Nurse Assistant Training Program Schedule

    CDPH 276 B SAMPLE Sample Daily Nurse Assistant Training Program Schedule

    CDPH 276 C

     

    Nurse Assistant Certification Training Program Individual Student Record

    CDPH 276 D

     

    Disclosure of Ownership and Control Interest Statement

    CDPH 276 F

    Skilled Nursing Facility (SNF) Nurse Assistant Certification Training Program Application

    CDPH 276 S

    School Nurse Assistant Certification Training Program Application

    CDPH 278 A

    Nurse Assistant Orientation Program Content

    CDPH 278 B

    In-Service Training Program

    CDPH 279

    Director of Staff Development/Instructor Application

    CDPH 283 A

     

    Certified Nurse Assistant In-Service Training/Continuing Education

    CDPH 283 B

     

    Certified Nurse Assistant and/or Home Health Aide Initial Application

    CDPH 283 C

     

    Certified Nurse Assistant and/or Home Health Aide Renewal Application

    CDPH 283 F

     

    Certified Hemodialysis Technician Initial Application

    CDPH 283 G

     

    Certified Hemodialysis Technician Renewal Application

    CDPH 283 I

     

    Transmittal for Criminal Background Clearance

    CDPH 318

    CNA/HHA Report of Misconduct

    CDPH 322

     

    Transmittal Application for Criminal Record Clearance

    CDPH 325

    Criminal Record Clearance Submissions

    CDPH 327

    Complete Package with Attachments-California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities

  • CDPH 327:  California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities
  • Table of Contents
  • Attachment A:  Facility Owner and Licensee Identification
  • Attachment B-1:  Supplies and Services Covered in the Basic Daily Rate for Private Pay and Privately Insured Residents
  • Attachment B-2:  Optional Supplies and Services Not Covered in the Basic Daily Rate for Private Pay and Privately Insured Residents
  • Attachment C-1:  Supplies and Services Included in the Basic Daily Rate for Medi-Cal Residents
  • Attachment C-2:  Supplies and Services Not Included in the Medi-Cal Basic Daily Rate That Medi-Cal Will Pay the Dispensing Provider for Separately
  • Attachment C-3:  Optional Supplies and Services Not Covered by Medi-Cal That May Be Purchases by Medi-Cal Residents
  • Attachment D-1:  Supplies and Services Covered by the Medicare Program for Medicare Residents
  • Attachment D-2:  Optional Supplies and Services Not Covered by Medicare That May Be Purchased by Medicare Residents
  • Attachment E:  Authorization for Disclosure of Medical Information
  • Attachment F:  Resident Bill of Rights 
  • Attachment F:  Resident Bill of Rights (12-Point Font)
  • CDPH 327

    Complete Package with Attachments-California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities

    CDPH 327 Chinese
    CDPH 327 Korean
    CDPH 327 Spanish
    CDPH 327 Vietnamese
    CDPH 327 Braille File Format

     

    CDPH 391

     

    Hemodialysis Technician/Patient Care Technician Training Program Application

    CDPH 414

    Application for Health Facility Change of Location

    CDPH 501

    Administrator in Training (AIT) Evaluation Report

    CDPH 502

    Instructions

     

    Application for AIT Program

    CDPH 502 A

     

    Application for Educational Waiver for AIT Program

    CDPH 503

    Application for Nursing Home Administrator State Examination

    CDPH 505

    Application for Nursing Home Administrator National Examination

    CDPH 506

    Application for Nursing Home Administrator License

    CDPH 508 

    Application to Become a Provider of Continue Education

    CDPH 509

    Continuing Education Course Completed for Active License Renewal

    CDPH 510

    Declaration and Request for Replacement License

    CDPH 511

    Instructor Application for C.E. Credit

    CDPH 512

    License Renewal Affidavit for Nursing Home Administrators

    CDPH 513

    Licensee's Request for Course Approval

    CDPH 514

    NHA/Facility Profile Sheet

    CDPH 515

    Preceptor Continuing Education Credit Application

    CDPH 516

    NHAP Preceptor Training Registration Form

    CDPH 518

    Provider Request for Course Approval

    CDPH 519

    Provider Request for Course Renewal

    CDPH 522

    Request for Provider Renewal

    CDPH 523

    Special Accommodation Request for Examination

    CDPH 524

    Master's or Reciprocity Application for Nursing Home Administrator

    CDPH 525

    Application for Provisional License

    CDPH 526

     

    AIT Program Application for Re-Training

    CDPH 530

    Nursing Staffing Assignment sign-in Sheet

    CDPH 609

    Bed or Service Request

    CDPH 611 

    Licensing and Certification for an Affiliate Primary Care Clinic Application

    CDPH 612

    Census and Nursing Hours Per Patient Day

    CDPH 709

    Client Accommodations Analysis

    CDPH 929

     

    Request for Name/Address Change and/or Duplicate for CNA/HHA/CHT Certification

    CDPH 930

    Request for Adult Day Health Care (ADHC) Center Moratorium Exemption

    CDPH 931

    Verification of Current Nurse Assistant Certification

    CDPH 5000

    Program Flexibility

    CDPH 5000 A

     

    Temporary Permission for Emergency Program Flexibility

    CMS 1561

    Health Insurance Benefit Agreement

    CMS 1561A

    Health Insurance Benefit Agreement (Rural Health Clinics)

    CMS 1572 (a)(b)

    Home Health Agency Survey and Deficiencies Report

    CMS 29

    Instructions for Completing Request to Establish Eligibility to Participate in the Health Insurance for the Aged and Disabled Program to Provide Rural Health Clinic Services

    CMS 3070 G

    Intermediate Care Facility for Persons with Mental Retardation Survey Report

    CMS 671

    LTC Facility Application for Medicare and Medi-Cal

    CMS 855A

    Medicare Enrollment Application

    DHCS 1051

    Civil Rights Compliance Review

    DHCS 9098

    Instructions for Completion of the Medi-Cal Provider Agreement (Institutional Provider)

    HHS 690

    Assurance of Compliance
    Medicare Certification Civil Rights Information Request Form

    HS 112

    Consultation Request

    HS 200

    License & Certification Application

    HS 215A

    Applicant Individual Information

    HS 269 

    Application for Medi-Cal Certification as a Primary Care Clinic Provider

    HS 309 

    Administrative Organization

    HS 328

    Notice - Effective Date of Provider Agreement

    HS 400

    Affidavit Regarding Patient Money

    HS 402

    Surety Bond Verification

    HS 403

    Financial Statement

    HS 602

    Transfer Agreement Between

    HS 610

    Medically Underserved or Health Professional Shortage Areas

    PM 284 (Eng/SP)

    Sterilization Consent Form (Non-Federally Funded)

    STD 850

    Fire Safety Inspection Request

     
     
    Last modified on: 1/3/2014 2:51 PM