Applications for Licensing and/or Certification of Skilled Nursing Facility or Intermediate Care Facility

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

In addition to the forms below, you are required to submit additional documents for a change of ownership.  These documents must be submitted with your completed application.  The required information and instructions are listed on the checklist contained in the “Skilled Nursing Facility or Intermediate Care Facility Application Request Letter and Instructional Checklist” letter.

Skilled Nursing Facility or Intermediate Care Facility  

Required Forms to be Licensed:

• Licensure & Certification Application:  HS 200
• Applicant Individual Information:  HS 215A
• Administrative Organization:  HS 309
• Affidavit Regarding Patient Money:  HS 400
• Surety Bond Verification:  HS 402
• Transfer Agreement Between:  HS 602
• Bed or Service Request:  CDPH 609
• Civil Rights Compliance Review (Title VI, Section 504, ADA):  DHCS 1051

Nursing Facility or Intermediate Care Facility  

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

• Notice - Effective Date of Provider Agreement:  HS 328 
• Medi-Cal Provider Agreement:  DHCS 9098  

Skilled Nursing Facility

Required Forms to be Certified with Medicare:

• Notice - Effective Date of Provider Agreement:  HS 328  
• Long Term Care Facility Application for Medicare and Medicaid:  CMS 671
• Medicare Enrollment Application:  CMS 855A
• Health Insurance Benefits Agreement:  CMS 1561 
• 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