Ambulatory Surgery Center
Initial Application Packet

A clinic may be certified as an ambulatory surgery center (ASC). An ASC facility means “any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following an admission,” pursuant to Title 42 Code of Federal Regulations (CFR) section 416.2.​

General Medicare Process Reminder

Providers seeking Medicare certification must first complete and submit an enrollment application through the Centers for Medicare and Medicaid Services (CMS), prior to submitting an ASC application packet to the Centralized Applications Branch (CAB). Information on Medicare enrollment, applicable forms, and instructions can be found at the CMS website​ (https://www.cms.gov/medicare/provider-enrollment-and-certification). If you receive a recommendation of approval letter from the Medicare Administrative Contractor (MAC) for California, Noridian Healthcare Solutions, please include a copy of this letter along with your ASC application packet to CAB. 

To apply for an Initial certification, you must complete the required application packet. Refer to 42 CFR Part 416 for information regarding certification requirements.

How to Apply

An applicant must submit a completed application packet to 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 certification. 

Please refer to the following links to get started:

• Provider Instructions​ (PDF)​
• Provider Checklist​
  

Application Packet Forms

• ​HS 200 - Licensure and Certification Application (PDF, 1.5MB​)​
  
• HS 215A - Applicant Individual Information (PDF)​
  
• ​​HS 309 - Administrative Organization and Organizational Structure (PDF) 
  
• HS 602 - Transfer Agreement (PDF)
  
• ​CMS 370 - Health Insurance Benefit Agreement (PDF) 
  
• CMS 377 - Ambulatory Surgical Center Request for Initial Certification (PDF)
  
• CMS 855B -  Medicare General Enrollment Health Care Provider/ Supplier Application​​ (PDF)​
  
• DHCS 9098 - ​​​Medi-cal Provider Agreement (PDF)​
  
• STD 850 - Fire Safety Inspection Request​ (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 Division
          Centralized Applications Branch
          P.O. Box 997377, MS 3207
          Sacramento, CA 95899-7377