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

Hospice Agency and Hospice Facility

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

Items 1, 2, 3, 4

Item 2 supporting document: IRS Tax ID Verification

Page 7, Section C

Items 3, 5

Page 11, Section D

Items 1, 2

Page 12, Section G

Signature(s)

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 9098 (PDF)

Medi-Cal Provider Agreement

Do not leave any questions blank. Enter “N/A” if not applicable
Pages 2-13 must be submitted. Do not omit any of those pages from submission
The mailing address must be the same as reported on the HS 200 form, page 3, section C, item 4
Complete the zip code fields with nine digits for all addresses

Notarized signature page is required

If out of state, notary public seal/stamp should be entered in the space provided on page 12, item 5

Submit the “Acknowledgement” page from the notary public if the notary is from California

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 417 (PDF)	Hospice Request for Certification in Medicare [HSC section 1749(b)(1) - (b)(7); SQHC, 2003, section 2.1] The form requires a signature and date If this freestanding hospice is “licensed only,” complete this form to identify the types of services
CMS 643 (PDF)	Hospice Survey & Deficiency Report Fill out the name of facility only Submit both pages
CMS 855A (PDF)	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: Sign the bottom signature block entitled “Accepted for the Successor Provider of Services By”
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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