HEALTH CARE FACILITY LICENSING AND CERTIFICATION

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Phone: (916) 552-8632

For application status requests, please include the following in your email:

Application ID (if applicable)
Name of Facility or Agency
License or Facility/Agency # (if applicable)
Address
Facility or Provider Type
Date Documentation Sent
Contact Number

Chronic Dialysis Clinic/End-Stage Renal Disease

Report of Change Application Checklist for Change of Certification

The following is a list of application forms and supporting documents required for a complete application packet. Failure to include each of the forms and documents will delay processing.

Medi-Cal
Medicare

Checklist and Instructions - Please submit your documents in this order

Required Documents for a Change of Certification

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

Cover Letter

Letter on company letterhead with the following information:

License number (only applicable for CHOW)
Facility name and address
Facility ID number (if known)
Brief description of request
Attestation that the applicant provider is located in proximity, in time and distance, to a facility with the capacity for management of obstetrical and neonatal emergencies, including the ability to provide cesarean section delivery, within 30 minutes from time of diagnosis of the emergency. Include the facility name and address with the capacity for management of obstetrical and neonatal emergencies
Contact information (name, title, phone number, and e-mail address)
Emergency Contact Information (name, email, alternate email, phone, fax, and phone number that will receive text messages). The Department will use this information to contact the provider in the event of an emergency using the California Health Alert Network (CAHAN). All information provided must allow CAHAN to contact the provider on a 24/7/365 basis for distribution of health alerts. For additional information: CAHAN (https://www.calhospitalprepare.org/cahan)
Signature

HS 200 (PDF, 1.5MB)

Licensure & Certification Application

[Health and Safety Code (HSC) Section 1212]

Complete the following:

Page 1, Section A

Items 1, 3, 4, 5, 6

Page 3, Section B

Item 6: An organization must own 100 percent of the licensee to be considered a parent company. This parent company will have its own Employer Identification Number (EIN)

Page 7, Section C

Items 3 and 5

Tip:

Page 9, Section 5 - When listing the names of individuals with direct or indirect ownership of the facility in section C, provide the EIN (do not enter a Social Security number on the HS-200 form)

Page 17, Attachment F–1

Medi-Cal Certification Documents

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
DHCS 1051 (PDF)	Civil Rights Compliance Review Send directly to Office of Civil Rights – address is on last page of the form
DHCS 9098 (PDF)	Medi-Cal Provider Agreement Do not leave any questions blank. Enter “same" or “N/A" if not applicable The mailing address must be the same as reported on the HS 200 form, page 3, section C, item 4 Notarized signature page is required Submit the "Acknowledgement" page from the notary public
HS 328 (PDF)	Notice - Effective Date of Provider Agreement If applying for both Medi-Cal & Medicare certification, only submit one copy of this form

Medicare Certification Documents

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
CMS 855A	Medicare Enrollment Application (Institutional Providers) This application is from the Federal Department of Health and Human Services The completed application should be mailed directly to the appropriate fiscal intermediary
CMS 1561 (PDF)	Health Insurance Benefit Agreement Submit two (2) signed copies: CHOC: Sign the bottom signature block entitled “Accepted for the Successor Provider of Services By"
CMS 3427 (PDF)	ESRD Application Notification and Survey Report Items 1-24 must be completed with applicable information. The surveyor will bring a copy of the form to update and add information when the certification survey is conducted
EIN Verification	EIN IRS Verification Letter: Submit one of the following letters: Form 941 (Employer's Quarterly Federal Tax Return) Form 8109-C (FTD Address Change) Letter 147-C (EIN Confirmation Notification) Form SS-4 (Confirmation Notification)
HHS 690 (PDF)	Assurance of Compliance OCR's online portal is: Office for Civil Rights (https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf) Once the on-line submission is completed, an electronic notification from OCR stating the “Assurance of Compliance form was submitted successfully" will be sent to the applicant Submit a copy of this notification

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