General Acute Care Hospitals and Acute Psychiatric Hospitals
Change of Certification
Required Documents
Online Application PDF Form
- Embedded and generated by online system
Facility Information - Medicare Certification Documents (Only applicable for Medicare Certification)
- āCMS 1561 (PDF) form - Health Insurance Benefit Agreement
- HS 328 (PDF) form - Notice-Effective Date of Provider Agreement
- HHS 690 (PDF) form - Assurance of Compliance (Submit a verification from the Office of Civil Rights displaying submission of this form)ā
Facility Information - Medi-Cal Certification Documents (Only applicable for Medi-Cal Certification)āā
- DHCS 9098 (PDF) form ā Medi-Cal Provider Agreement
- DHCS 6207 (PDF) form ā Medi-Cal Disclosure Statement (Only submit Section V ā Subcontractor Information and Significant Business Transactions)
- One of the following Internal Revenue Service tax documents: ā
- Form 941 ā Employerās Quarterly Federal Tax Return
- Form 8109-C ā FTD Address Change
- Letter 147-C ā EIN Verification Letterā
- Form SS-4 ā Application for Employer Identification Number
- HS 328ā (PDF) form - Notice-Effective Date of Provider Agreementāā