Referral Agency
Change of Governing Board Application Packet

A State license is required to operate as a Referral Agency (REFRLAG) in California. REFRLAG means “a private, profit or nonprofit agency which is engaged in the business of referring persons for remuneration to any health facility,” pursuant to Title 22 of the California Code of Regulations (CCR) section 74019.

To report a Change of Governing Board, you must complete the required application packet. Refer to Title 22 CCR sections 74001 through 74515 and Health and Safety Code sections 1400 through 1413 for licensure requirements.

How to Apply

An applicant must submit a completed application packet to the Centralized Applications Branch (CAB). The application packet contains the required forms in one location. The provider checklist identifies the required forms and supporting documents needed to apply for licensing and certification. The provider instructions are a resource to guide you through the process. 

Please refer to the following links to get started:

• Provid​er 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)​​​
  

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