Applications for Licensing and/or Certification of a HOSPICE

In addition to the forms below, you are required to submit additional documents for a Change of Ownership and the Geographic Location of the BRANCH Office.  These documents must be submitted with your completed application.  The required information and instructions are listed on the checklist contained in the “Hospice Application Request Letter and Instructional Checklist”  (PDF)letter.

Hospice

Required Forms to be Licensed:

• Licensure & Certification Aplication: HS 200 (PDF)
• Application Individual Information: HS 215A (PDF)
• Administrative Organization: HS 309 (PDF)
• Hospice Request for Certification in the Medicare Program: CMS 417 (PDF)

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

• Notice - Effective Date of Provider Agreement: HS 328 (PDF)
• Medi-Cal Provider Agreement: DHCS 9098 (PDF)
• Hospice Request for Certification in the Medicare Program: CMS 417 (PDF)

Required Forms to be Certified with Medicare:

• Notice - Effective Date of Provider Agreement: HS 328 (PDF)
• Hospice Request for Certification in the Medicare Program: CMS 417 (PDF)
• Hospice Survey and Deficiencies Report:  CMS-643 (PDF)
• Medicare Enrollment Application: CMS 855A (PDF)
• Health Insurance Benefit Agreement: CMS 1561 (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
• Assurance of Compliance: HHS 690 (PDF)

Hospice – ADDING ALTERNATE SITE TO HOSPICE LICENSE

Required Forms for an Alternate Site to be Licensed:

• Licensure & Certification Aplication: HS 200 (PDF)
• Hospice Survey and Deficiencies Report:  CMS-643 (PDF)
• Medicare Enrollment Application: CMS 855A (PDF)