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:

Name of Facility or Agency
License or Facility/Agency # (if applicable)
Address
Facility or Provider Type
Date Documentation Sent
Contact Number

Intermediate Care Facility/Developmentally Disabled
Intermediate Care Facility/Developmentally Disabled-Habilitative
Intermediate Care Facility/Developmentally Disabled-Nursing
Intermediate Care Facility/Developmentally Disabled-Continuous Nursing

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

Checklist and Instructions - Please submit your documents in this order

Required Documents for a Medi-Cal Certification

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 Facility ID number (if known) Brief description of request to add Medi-Cal [Title 19] 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 and Certification Application Note: If applying for Med-Cal, applicant must complete the “Subcontractor Information and Significant Business Transactions” attachment Tip: Page 6, section B, item 6 — An organization will have its own Federal tax ID number
CMS 3070G (PDF)	Intermediate Care Facilities for Individuals with Intellectual Disabilities Survey Report This is a “survey” report. The applicant only needs to complete the top portion of the form - the remainder will be completed during the survey.
HS 328 (PDF)	Notice - Effective Date of Provider Agreement If applying for both Medi-Cal & Medicare certification, only submit one copy of this 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, section C, Page 3, item 4 Notarized signature page is required Submit the “Acknowledgement” page from the Notary Public

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