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

Psychology Clinic

Report of Change Application Checklist for Change of Mailing Address

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.

Checklist and Instructions - Please submit your documents in this order

Required Documents for a Change of Mailing Address

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
Facility name and address
Facility ID number (if known)
Brief description of request
Indicate if the change of mailing address is for the Licensee or for the facility
Contact information (name, title, phone number, and
email 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

[Title 22 California Code of Regulation (CCR) sections 75311, 75317]

Tip

Attachment F-1 — If the current or proposed facility, agency, or clinic is applying for Medi-Cal certification, complete Attachment F-1: Subcontractor Information and Significant Business Transactions

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, section C, Page 3, item 4 Notarized signature page is required Submit the “Acknowledgement” page from the notary public

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

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