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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.

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.Opens a new browser window

Affiliate Primary Care Clinic – Community, Free or Mobile Clinic

Required Forms to be Licensed:

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


Last modified on: 8/15/2012 11:02 AM