Hospice Agency
Change of Governing Board Application Packet

A State license is required to operate as a Hospice Agency in California. A Hospice means "a specialized form of interdisciplinary health care that is designed to provide palliative care, alleviate the physical, emotional, social, and spiritual discomforts of an individual who is experiencing the last phases of life due to the existence of a terminal disease, and provide supportive care to the primary caregiver and the family of the hospice patient," pursuant to Health and Safety Code section 1746(d).

To report a Change of Governing Board, 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 ​
  

Application Packet Forms​

• HS 200 – Licensure and ​​Certification Application (PDF, 1.5MB)
• HS 2​​15A – Applicant Individual Information (PDF)
• HS 309 – Administrative Organization (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