Applications for Licensing and/or Certification of a Primary Care Clinic or Rural Health Clinic
The following forms and documents are required for licensure and/or certification.
A Clinic Exemption list can be found here
(after clicking link, please click first search result, then scroll to Section 1206).
In addition to the forms below, you are required to submit additional documents for a change of ownership and for a Mobile Clinic and Affiliate Clinic (if applicable). These documents must be submitted with your completed application. The required information needed and instructions are listed on the checklist contained in the Clinic Facility Application Request Letter and Instructional Checklist
letter.
Community or Free Clinic
To be licensed only:
Community or Free Clinic
To be licensed and certified with Medicaid/Medi-Cal:
Mobile Clinics
To be licensed as a Primary Care Clinic (Community Clinic or Free Clinic)
Mobile Clinics
To be licensed and certified with Medicaid/Medi-Cal:
Rural Health Clinic
To be licensed as Primary Care Clinic and certified with Medicaid/Medi-Cal/Medicare:
Rural Health Clinic
To be certified with Medicare: