Rehabilitation Clinic and Comprehensive Outpatient Rehabilitation Facility 

Change of Certification Application Packet​

A State license is required to operate a Rehabilitation Clinic (REHABC) in California. A REHABC means “a clinic that, in addition to providing medical services directly, also provides physical rehabilitation services for patients who remain less than 24 hours. Rehabilitation clinics shall provide at least two of the following rehabilitation services: physical therapy, occupational therapy, social, speech pathology, and audiology services. A rehabilitation clinic does not include the offices of a private physician in individual or group practice,” pursuant to Health and Safety Code (HSC) section 1204(b)(3). A REHABC may also apply for certification as a Comprehensive Ou​​​tpatie​nt Rehabilitation Facility (CORF). A CORF is a nonresidential facility that is established and operated exclusively for the purpose of providing diagnostic, therapeutic, and restorative services to outpatients for the rehabilitation of injured, disabled, or sick persons, at a single fixed location, by or under the supervision of a physician who may provide influenza, pneumococcal and Hepatitis B vaccines provided the applicable conditions of coverage are met, pursuant to Title 42 Code of Federal Regulations (CFR) section 485.51. 

To report a Change of Service, you must complete the required application packet. Refer to HSC sections 1200 through 1245 for information regarding licensure requirements. Refer to 42 CFR Part 485, Subpart B for the Conditions Of Participation For Comprehensive Outpatient Rehabilitation Facilities.

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 - Effective Date of Provider Agreement ​(PDF)​
• CMS 359 - Comprehensive Outpatient Rehab Facility Report ​(PDF)​
• CMS 855A - Medicare Enrollment Application (Institutional Providers)​ (PDF) 
• CMS 1561​ - Health Insurance Benefit Agreement (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