HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Contact Us

Phone: (916) 552-8632
Email: CAB@cdph.ca.gov

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

Skilled Nursing Facility and Intermediate Care Facility

Report of Change Application Checklist for Change of Name

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.

Facility
Licensee

Checklist and Instructions - Please submit your documents in this order

Required Documents to Change the Name of the Facility or Licensee

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
Cover Letter	Cover Letter Letter on company letterhead with the following information: License number Facility name and address Indicate if the change of the name is for the Licensee and/or the Facility Facility ID number (if known) Brief description of request Previous and proposed/new name 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/post/california-health-alert-network-cahan) Contact Information for the Privacy Officer or Designee responsible for submitting and responding to medical breach incidents (name, title/position, mailing address, phone number, and email address) Signature
HS 200 (PDF, 1.5MB)	Licensure & Certification Application SNF: Title 22 of the California Code of Regulations (CCR) section 72201 ICF: 22 CCR section 73203 Tips Page 6, section B, item 6 — An organization will have its own Federal tax ID number
Supporting Documents	Board Resolution SNF: [22 CCR section 72211] ICF: [22 CCR section 73205 (a)(11)] Submit a copy of board resolution signed by officers and directors authorizing the facility name change and with the effective date.
Supporting Documents	Articles of Incorporation/ Organization SNF: [22 CCR section 72211] ICF: [22 CCR section 73205 (a)(11)] If the Licensee name, LLC name, or Corporate name changes, submit a copy of amended Articles of Incorporation filed with the CA Secretary of State. Note: In case of entity conversion, submit a copy of conversion document (PDF) filed with the CA Secretary of State

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 “same” or “N/A” if not applicable
The mailing address must be the same as reported on the HS 200 form
Notarized signature page is required
Submit the “Acknowledgement” page from the notary public, if applicable

Medicare Certification Documents

Forms and Supporting Documents

Additional Instructions
(Each form listed also has instructions on the form)

CMS 855A (PDF)

Medicare General Enrollment Health Care Provider/ Supplier Application

This application is from the Federal Department of Health and Human Services
The completed application should be mailed directly to the appropriate fiscal intermediary
This document does not go to CAB

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