Applications for Licensing and/or Certification of an Intermediate Care Facility for the Developmentally Disabled

The following forms and documents are required for licensure and/or certification. 

In addition to the forms below, you are required to submit additional documents for a change of ownership plus information regarding your Program Plan, and Consultants. These documents must be submitted with your completed application. The required information needed and instructions are listed in the checklist contained in the Intermediate Care Facility For the Developmentally Disabled Application Request Letter and Instructional Checklist letter.

Intermediate Care Facility/Developmentally Disabled,
Intermediate Care Facility/Developmentally Disabled-Habilitative, &
Intermediate Care Facility/Developmentally Disabled-Nursing

Required Forms to be Licensed:

• Licensure & Certification Application:  HS 200
• Applicant Individual Information:  HS 215A 
• Administrative Organization:  HS 309
• Transmittal Application for Criminal Background Investigation:  CDPH 322
• Criminal Record Clearance Submissions:  CDPH 325
• Affidavit Regarding Patient Money:  HS 400  
• Surety Bond Verification:  HS 402 
• Transfer Agreement Between:  HS 602 
• Civil Rights Compliance Review (Title VI, Section 504, ADA):  DHCS 1051  
• Request for Live Scan Service: BCIA 8016  ...Sample Form
  (For correct application routing, please fill in BCIA 8016 ORI field with A1226)

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

• Notice - Effective Date of Provider Agreement:  HS 328 
• Medi-Cal Provider Agreement:  DHCS 9098 
• Intermediate Care Facility for Persons With Mental Retardation Survey Report:  CMS 3070 G