Ambulatory Surgery Center
Change of Certification Application Packet

A clinic may be certified as an ambulatory surgery center (ASC). An ASC facility means "any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following an admission", pursuant to Title 42 Code of Federal Regulations (CFR) section 416.2.

To apply for an Initial certification, you must complete the required application packet. Refer to 42 CFR Part 416 for information regarding certification requirements.

How to Apply

An applicant must submit a completed application packet to the Centralized Applications Branch (CAB). The provider instructions are a resource to guide you through the process. The provider checklist identifies the required forms and supporting documents needed to apply for licensing.

Please refer to the following links to get started:

• Provider Instructions
• Provider Checklist

Application Packet Forms

• HS 200 - Licensure and Certification Application  (PDF, 1.5MB)
• DHCS 9098 - Medi-Cal Provider Agreement (PDF)
• HS 328 - Notice of Effective Date of Provider Agreement (PDF)
• CMS 370 - Health Insurance Benefit Agreement (PDF)
• CMS 377 - Ambulatory Surgical Center Request for Initial Certification (PDF)
• CMS 855A -  Medicare Enrollment Application (Institutional Providers) (PDF)
• HHS 690 - Assurance of Compliance (PDF)

Where to Submit Applications

Submit completed application packets to the CAB at the address listed below. Do not send any completed application packets, forms, or supporting documents to the local CDPH, District Office.

          California Department of Public Health
          Licensing and Certification Program
          Centralized Applications Branch
          P.O. Box 997377, MS 3207
          Sacramento, CA 95899-7377​