Home Health Agency 
Initial Application Packet

A State license is required to operate as a Home Health Agency (HHA) in California. An HHA means "a private or public organization, including but not limited to, any partnership, corporation, political subdivision of the state, or other government agency within the state, which provides, or arranges for the provision of, skilled nursing services, to persons in their temporary or permanent place of residence", pursuant to Title 22 of the California Code of Regulations (CCR) section 74600(a).

To apply for an Initial license, you must complete the required application packet.

How to Apply

An applicant must submit a completed application packet to the Centralized Applications Branch (CAB). The application packet contains the required forms in one location. The provider checklist identifies the required forms and supporting documents needed to apply for licensing and certification. The provider instructions are a resource to guide you through the process. The Sample Application Packet is a visual aid that displays a sample of the completed forms contained in the application packet.

Please refer to the following links to get started:

• Provider Instructions (PDF)
• Provider Checklist ​
  

Applicatio​​n Packet Forms

• ​HS 200 - Licensure and Certification Application (PDF)
• HS 215A - Applicant Individual Information (PDF)​
• ​​HS 309 - Administrative Organization and Organizational Structure (PDF)
• CDPH 322 - Transmittal Application for Criminal Record Clearance (PDF) 
  
• CDPH 325 - Criminal Record Clearance Submissions (PDF)
  
• BCIA 8016 - Request for Live Scan (PDF) 
  
• HS 328 - Notice of Effective Date of Provider Agreement ​(PDF)
  
• DHCS 9098 - ​​​Medi-cal Provider Agreement (PDF)
  
• CMS 671 - Long Term Care Facility Application for Medicare & Medicaid (PDF)
  
• CMS 1561 - Health Insurance Benefits Agreement (PDF)
  
• CMS 1572 - Home Health Agency Survey and Deficiency Report​ (PDF)
  
• CMS 855A - Medicare General Enrollment Health Care Provider/Supplier Application​ (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