Applications for Licensing and/or Certification of a Home Health Agency (HHA)

In addition to the forms below, you are required to submit additional documents for a Change of Ownership; the Geographic Location of the BRANCH Office; and the Capitalization information for Medi-Cal certification “only”.  These documents must be submitted with your completed application.  The required information and instructions are listed on the checklist contained in the Home Health Agency Application Request Letter and Instructional Checklist letter.

Home Health Agency (HHA)

Required Forms to be Licensed:

• Licensure & Certification Application:  HS 200
• Applicant Individual Information:  HS 215A
• Administrative Organization:  HS 309  
• Transmittal Application for Criminal Background Investigation:  HS 322
• Criminal Record Clearance Submissions:  CDPH 325
• Request for Live Scan Service: BCIA 8016  ...Sample Form
  (For correct application routing, please fill in BCIA 8016 ORI field with A1226)
• Home Health Agency Survey and Deficiencies Report:  CMS 1572(a)(b)

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

• Notice - Effective Date of Provider Agreement:  HS 328  
• Medi-Cal Provider Agreement:  DHCS 9098
• Home Health Agency Survey and Deficiencies Report:  CMS 1572(a)(b)

Required Forms to be Certified with Medicare:

• Notice - Effective Date of Provider Agreement:  HS 328  
• Medicare General Enrollment Health Providers/Supplier Application: CMS 855A
• Health Insurance Benefits Agreement:  CMS 1561
• Home Health Agency Survey and Deficiencies Report:  CMS 1572(a) (b)
• Civil Rights Information Request for Medicare Certification:  OMB No. 0990-0243 
  For additional Civil Rights Information, please visit the U.S. Department of Health and Human Services
• Assurance of Compliance:  HHS 690

Home Health Agency – BRANCH OFFICE

Required Forms for a Branch Office to be Licensed:

• Licensure & Certification Application:  HS 200
• Medicare General Enrollment Health Providers/Supplier Application: CMS 855A
• Home Health Agency Survey and Deficiencies Report:  CMS 1572(a) (b)