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 Checklistletter.

Community or Free Clinic

To be licensed only:

• Licensure & Certification Application:  HS 200 (PDF)
  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”. (PDF)
• Applicant Individual Information:  HS 215A (PDF)
• Administrative Organization:  HS 309 (PDF)
• Transfer Agreement Between:  HS 602 (PDF)
• Bed or Service Request:  HS 609 (PDF)
• Fire Safety Inspection Request:  STD 850 (PDF)
• Civil Rights Compliance Review (Title VI, Section 504, ADA):  DHCS 1051 (PDF)

Community or Free Clinic

To be licensed and certified with Medicaid/Medi-Cal:

• Licensure & Certification Application:  HS 200 (PDF)
  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”. (PDF)
• Applicant Individual Information:  HS 215A (PDF)
• Administrative Organization:  HS 309 (PDF)
• Transfer Agreement Between:  HS 602 (PDF)
• Bed or Service Request:  HS 609 (PDF)
• Fire Safety Inspection Request:  STD 850 (PDF)
• Civil Rights Compliance Review (Title VI, Section 504, ADA):  DHCS 1051 (PDF)
• Application for Medi-Cal Certification as a Primary Care Clinic Provider:  HS 269 (PDF)
• Notice - Effective Date of Provider Agreement:  HS 328 (PDF)
• Medi-Cal Provider Agreement:  DHCS 9098 (PDF)

Mobile Clinics

To be licensed as a Primary Care Clinic (Community Clinic or Free Clinic)

• Licensure & Certification Application:  HS 200 (PDF)
• Applicant Individual Information:  HS 215A (PDF)
• Administrative Organization:  HS 309 (PDF)
• Transfer Agreement Between:  HS 602 (PDF)
• Bed or Service Request:  HS 609 (PDF)
• Civil Rights Compliance Review (Title VI, Section 504, ADA):  DHCS 1051 (PDF)

Mobile Clinics

To be licensed and certified with Medicaid/Medi-Cal:

• Licensure & Certification Application:  HS 200 (PDF)
• Applicant Individual Information:  HS 215A (PDF)
• Administrative Organization:  HS 309 (PDF)
• Transfer Agreement Between:  HS 602 (PDF)
• Bed or Service Request:  HS 609 (PDF)
• Civil Rights Compliance Review (Title VI, Section 504, ADA):  DHCS 1051 (PDF)
• Application for Medi-Cal Certification as a Primary Care Clinic Provider:  HS 269 (PDF)
• Notice - Effective Date of Provider Agreement:  HS 328 (PDF)
• Medi-Cal Provider Agreement:  DHCS 9098 (PDF)

Rural Health Clinic

To be licensed as Primary Care Clinic and certified with Medicaid/Medi-Cal/Medicare:

• Licensure & Certification Application:  HS 200 (PDF)
  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”. (PDF)
• Applicant Individual Information:  HS 215A (PDF)
• Administrative Organization:  HS 309 (PDF)
• Transfer Agreement Between:  HS 602 (PDF)
• Bed or Service Request:  HS 609 (PDF)
• Fire Safety Inspection Request:  STD 850 (PDF)
• Civil Rights Compliance Review (Title VI, Section 504, ADA):  DHCS 1051 (PDF)
• Application for Medi-Cal Certification as a Primary Care Clinic Provider:  HS 269 (PDF)
• Notice - Effective Date of Provider Agreement:  HS 328 (PDF)
• Medi-Cal Provider Agreement:  DHCS 9098 (PDF)
• Medically Underserved or Health Professional Shortage Areas:  HS 610 (PDF)
• Request to Establish Eligibility: CMS 29 (PDF)
• Medicare Enrollment Application:  CMS 855A (PDF)
• Health Insurance Benefits Agreement:  CMS 1561A (PDF) 
• Assurance of Compliance:  HHS 690 (PDF)
• Civil Rights Information Request for Medicare Certification: OMB No. 0990-0243 (PDF)
  For additional Civil Rights Information, please visit the U.S. Department of Health and Human Services.

Rural Health Clinic

To be certified with Medicare:

• Licensure & Certification Application:  HS 200 (PDF)
• Applicant Individual Information:  HS 215A (PDF)
• Administrative Organization:  HS 309 (PDF)
• Medically Underserved or Health Professional Shortage Areas:  HS 610 (PDF)
• Request to Establish Eligibility: CMS 29 (PDF)
• Medicare Enrollment Application:  CMS 855A (PDF)
• Health Insurance Benefits Agreement:  CMS 1561A (PDF)
• Assurance of Compliance:  HHS 690 (PDF)
• Civil Rights Information Request for Medicare Certification: OMB No. 0990-0243 (PDF)
  For additional Civil Rights Information, please visit the U.S. Department of Health and Human Services.