Application for Licensing and/or Certification of an Affiliate Primary Care Clinic

The following forms and documents are required for licensure and/or certification.

How to apply for specified health programs simultaneously:
To learn about the process and obtain the forms to simultaneously apply for the following health programs as you apply for a clinic license, please reference the sites and documents below.

• Medi-Cal Presumptive Eligibility for Pregnant Women (PE)
• Child Health and Disability Prevention (CHDP) Program
• Comprehensive Perinatal Services Program (CPSP):  CDPH 4448
• Family Planning, Access, Care, and Treatment (Family PACT):  CDPH 4468

In addition to the forms below, you are required to submit additional documents for a Mobile Clinic. These documents must be submitted with your completed application.  The required information and instructions are listed on the checklist contained in the Affiliate Primary Care Clinic Application Request Letter and Instructional Checklist letter.

Affiliate Primary Care Clinic – Community, Free or Mobile Clinic

Required Forms to be Licensed:

• Licensure & Certification Application For An Affiliate Primary Care Clinic:  CDPH 611 
  Title 24 Building Requirements:  In lieu of a letter from a licensed architect, the licensed architect may use the attached form, Certification Form for Clinics and Freestanding Outpatient Clinic Services Of a Hospital. 
• Applicant Individual Information:  HS 215A
• Transfer Agreement Between:  HS 602
• Fire Safety Inspection Request:  STD 850
• Civil Rights Compliance Review (Title VI, Section 504, ADA):  DHCS 1051

Required Forms to be Certified with Medicaid/Medi-Cal:

• Application for Medi-Cal Certification as a Primary Care Clinic Provider:  HS 269
     
  Notice – Effective Date of Provider Agreement:  HS 328
• Medi-Cal Provider Agreement:  DHCS 9098