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Certification "Only" of a Rural Health Clinic (Non-Urbanized Area)

The following forms and documents are required for rural health clinic (RHC) certification (non-urbanized area).  Refer to the primary care clinic (PCC) application details for a list of forms for a RHC to be licensed as a PCC.  

In addition to the forms below, you are required to submit additional documents for a change of ownership (if applicable).  These documents must be submitted with your completed application.  The required information and instructions are listed on the checklist contained in the Rural Health Clinic (Non-Urbanized Area)Certification Request Letter and Instructional Checklist letter.Opens new browser window

 

Determination of Rural Health Clinic (Non-Urbanized Area) Status

Required Forms to Determine if a Clinic is in a Designated Rural Health (Non-Urbanized) Area:

If already licensed as a PCC, submit the following two (2) forms to the appropriate district office.  If NOT licensed as a PCC, submit these two (2) forms to the Centralized Applications Unit.

Rural Health Clinic (Non-Urbanized Area)

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

Required Forms to be Certified with Medicare:

Required Forms if Already a Licensed PCC and Want to be Certified with Medicaid/Medi-Cal as a RHC (Non-Urbanized Area):

Required forms if Already a Licensed PCC and Want to be Certified with Medicare as a RHC (Non-Urbanized Area):

 

 
 
Last modified on: 7/31/2013 4:10 PM