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Phone: (916) 552-8632

For application status requests, please include the following in your email:

  • Application ID (if applicable)
  • Name of Facility or Agency
  • License or Facility/Agency # (if applicable)
  • Address
  • Facility or Provider Type
  • Date Documentation Sent
  • Contact Number​​​​​

Alternative Birth Center

Initial and Change of Ownership Application Checklist 

The following is a list of application forms and supporting documents required for a complete application packet. Failure to include each of the forms and documents will delay processing.

  • Initial License
  • Change of Ownership (CHOW)
  • Medi-Cal

Checklist and Instructions - P​lease submit your documents in this order

Required Documents for an Initial License or CHOW 

Forms and Supporting​ Documents​

​​Additional Instructions

(​​​Each form listed also has instructions on the form)​

​Cover Letter

Cover Letter

Letter on company letterhead with the following information:

  • License number (only applicable for CHOW)
  • Facility name and address
  • Facility ID number (if known)
  • Brief description of request
  • Attestation that the applicant provider is located in proximity, in time and distance, to a facility with the capacity for management of obstetrical and neonatal emergencies, including the ability to provide cesarean section delivery, within 30 minutes from time of diagnosis of the emergency. Include the facility name and address with the capacity for management of obstetrical and neonatal emergencies [Health and Safety Code (HSC) section 1204.3(4)(A)]
  • Contact Information (name, title, phone number, and e- mail address)
  • Emergency Contact Information (name, email, alternate email, phone, fax, and phone number that will receive text messages). The Department will use this information to contact the provider in the event of an emergency using the California Health Alert Network (CAHAN). All information provided must allow CAHAN to contact the provider on a 24/7/365 basis for distribution of health alerts. For additional information: CAHAN (
  • Contact Information for the Privacy Officer or Designee responsible for submitting and responding to medical breach incidents (name, title/position, mailing address, phone number, and email address)
  • Signature​
HS 200 (PDF)

Licensure & Certification Application

[HSC Section 1212(a)]


  • ​Attachment F-1 — If the current or proposed facility, agency, or clinic is applying for Medi-Cal certification, complete Attachment F-1: Subcontractor Information and Significant Business Transactions
​Supporting Documents

A.10 – California Department of Health Care Access and Information (HCAI) [California Building Code section 1226 and Health and Safety Code (HSC) section 1226] And/ Or Certificate of Occupancy

One of the two documents are required:

  • ​Written certification: the local building authority must provide written certification of Title 24 compliance (OSHPD 3 Standards) stating the building meets the current applicable codes and the following building requirements:
    • California Building Code (CBC)
    • California Fire Code (CFC)
    • California Electrical Code (CEC)
    • California Mechanical Code (CMC)
    • California Plumbing Code (CPC)
    • California Administrative Code (CAC)
  • ​​​​​CDPH 270: Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital, to certify the facility conforms to current applicable Title 24 (OSHPD 3 Standards). This form must be signed by the local building authority

Note: Title 24 compliance does not apply to CHOWs unless there has been construction and/or remodeling
If construction occurred and if the construction resulted in a new building or addition:
  • Submit a Certificate of Occupancy
  • This is not applicable if there were alterations or repairs to existing buildings performed or conversion of space​
​Supporting Documents 
B.1 Licensee Name​

The licensee’s formal organization name must be consistent throughout all documents

​Supporting Documents

​B.3 - Organizational Chart 

[HSC section 1212(a)]​

Submit an organization chart/flow chart if the owner is a profit or nonprofit corporation, limited liability company (LLC), or general partnership. The organization chart needs to display the following:

  • Applicant’s owners, directors, board members, corporate officers, LLC members/managers, and partners.
    Note: Submit the HS 215A form for each of these individuals
  • Parent company of applicant, if applicable, and all of the licensed agencies/facilities they are operating – see B.6

​Supporting Documents
B.3 Internal Revenue Service Documentation

[HSC section 1212(a)]

Submit one of the following IRS tax documents showing entity’s legal name and Tax Identification Number:

  • ​Form 941- Employer’s Quarterly (Federal Tax Return)
  • Form 8109- C (FTD Address Change)
  • Letter 147-C (EIN Confirmation Notification)
  • Form SS-4 (Confirmation Notification)
Supporting Documents
B.3 – Non Profit Status – Owner Type
[HSC section 1212(a)]

Submit a copy of the IRS Tax Exempt Determination Letter showing the non-profit 501(c)(3) status. (If Applicable)​
Supporting Documents
B.4.a Licensee’s “Other” Facility Involvement

Answer all aspects of the question

​Supporting Documents
B.4.b – License Revocation (if applicable)
[HSC section 1212(a)]

Submit additional information, including all ownership and facility information, date and any final action
​Supporting Documents 

​​​B.6 Organizational Chart

[HSC section 1212(a]

If there is a “subsidiary” (parent company) submit:

  • An organization chart with the parent company name
  • A listing of all owners, directors, board members, corporate officers, LLC members/managers, and partners of the parent company
    Note: Submit the HS 215A form for each of these individuals
  • A listing of all facilities the parent company is operating
​Supporting Documents

C.2.a Name of “Current Agency”

Note: If CHOW, enter current facility name

Supporting Documents​
​C.3.a – Name of “Proposed” Agency
Supporting Documents​
C.4.a Administrator

[HSC section 1212(a)]

Submit the HS 215A form for the administrator of the facility

​Supporting Documents 
C.5 – Ownership

[HSC section 1212(a)]​

  • ​List all individuals having 5% or more ownership, unless “nonprofit.”
  • Submit the HS 215A form for each of these individuals
​Supporting Documents 
D.1 – Control of Property

[HSC section 1212(a)]

Submit a copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed Licensee

​Supporting Documents
G.1 – Signature​

Signature is required and must be signed by the applicant (not the administrator unless the owner is the administrator)

HS 215A (PDF)​

Applicant Individual Information 

[HSC Section 1212(a)]

This form must be completed and signed for the following individuals:

  • Administrator of the facility
  • Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization and/or management company
  • Each individual having a beneficial interest of 5% or more in the applicant organization and/or parent organization [HSC Section 1212(a)]
  • Signature is required 


  • Page 2, section B — The date of birth is an identifier, as several people may have the same name. This will ensure that each individual is associated with the correct facility or entity
  • Page 5, section E — Submit ten years of employment history, indicating the start and end dates of employment, job title, employer name and address. The applicant may submit a resume in lieu of completing section E; however, the resume must contain all required information requested in section E
  • Page 7, section F — If answering yes to any question in this section, complete Section H: Facility Information Sheet
Supporting Documents 

Facility Information Sheet

Each individual must complete and submit the Facility Information Sheet for each facility and/or agency with which the individual has a current or past relationship within the last three years. This sheet must also include any facilities licensed by the California Department of Social Services. The following must be completed for each facility and/or agency:

  • Facility name
  • Facility address
  • Type of facility
  • Type of business entity (include EIN Number)
  • Individual’s nature of involvement
  • Individual’s dates of involvement
​Supporting Documents 


[HSC section 1212(a)]

A resume is required for the Administrator

HS 309 1st Page​ (PDF)

Administrative Organization

[HSC 1212(a)]

Along with the HS 309, the following supporting documents according to organizational type must be submitted:

Supporting Documents​
  • Filing Statement from the Secretary of State (only required if Articles of Incorporation are not endorsed by the CA Secretary of State)
  • Articles of Incorporation (endorsed by CA Secretary of State)
  • By-Laws (stating the size of board)
  • List of Board of Directors (only if additional space is needed to input all board of directors) 
​Note: Submit the HS 215A form for each individual listed as a board of director

  • Page 1, item 2 — The Administrator of Corporation LLC is usually the CEO/President
  • Page 1, item 3 — The incorporation date is located in the top right corner of the applicant Articles of Incorporation

Supporting Documents​

Limited Liability Company (LLC)

  • Filing Statement from the Secretary of State (only required if Articles of Organization are not endorsed by the CA Secretary of State)
  • Articles of Organization (endorsed by CA Secretary of State)
  • Operating Agreement
  • List of members, holders, officers, managers (only if additional space is needed to input all managing members) 

Note: Submit the HS 215A form for each individual listed as a member, holder, officer, or manager

Supporting Documents ​
Governing Board of Directors
  • Enter the number of members/managers
  • Submit the HS 215A form for each individual listed under this item

HS 309 2nd Page​ (PDF)

Organizational Structure 

[HSC section 1212(a)]

Only complete fields that are applicable to applicant’s entity type


  • Page 2, item 1 — For California Out-of-State Corporations, LLCs, etc. submit a copy of the Certificate of Qualification from the California Secretary of State
  • Page 2, item 5  — Must be completed for Corporations, LLCS, and Partnerships
​Supporting Documents

Public Agency

Submit a copy of signed Resolution

​Supporting Documents

  • Copy of signed Partnership Agreement
  • Copy of the California Secretary of State filing, if applicable
  • HS 215A form for each partner
STD 850 (PDF)

Fire Safety Inspection Request

[HSC section 1212(a)]

The STD 850 form must be submitted or a similar form from the local fire authority that contains equivalent information as the STD 850 form. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form

Note: This form is not required for a CHOW unless there has been construction and/or remodeling. ​

​DHCS 1051​ (PDF)
Civil Rights Compliance Review​

Send directly to the Office of Civil Rights - address is on the last page of the form​

​​Required Documents for a CHOW Only​

Forms and Supporting Documents​​​

Additional Instructions

(Each form listed also has instructions on the form) ​

Supporting Docum​ents

In addition to the forms required for an Initial application listed above submit the documents requested below:

[HSC section 1212(a)]

  • Copy of Purchase Agreement or Operating Transfer Agreement
  • Copy of Interim Management Agreement (If applicable)
  • A letter from the prospective licensee (to CDPH) stating where the stored patient medical records will be maintained, and that the records will be made available to the previous licensee

​​Medi-Cal Certification Documents 

Forms and Supporting Documents​​​

Additional Instructions

(Each form listed also has instructions on the form) ​

​​DHCS 9098 (PDF) 
Medi-Cal Provider Agreement​
  • Do not leave any questions blank. Enter “same” or “N/A” if not applicable
  • The mailing address must be the same as reported on the HS 200 form, section C, Page 8, item 3.c.1
  • Notarized signature page is required
  • Submit the “Acknowledgement” page from the notary public
HS 328 (PDF) 
Notice - Effective Date of Provider Agreement 
Submi​t one copy of the HS 328 form with signature

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