CDPH has revised the HS 200 (PDF) and HS 215A (PDF) forms. Use of the updated forms takes effect July 1, 2023. The purpose of the revision is to capture additional licensing and/or certification requirements in the application forms, provide clarity, and facilitate accurate completion of the forms.

The major updates to the HS 200 form include:

• the Medi-Cal disclosures related to the Subcontractor Information and Significant Business Transactions that were previously collected on the Medi-Cal Disclosure Statement (DHCS 6207)
• additional application types, facility types, and managing positions
  

The major updates to the HS 215A form include:

• additional facility information
• additional application types
• a request for a copy of applicant's Driver's License or State-Issued identification card and Social Security Number
  

The revised forms will be in production effective July 1, 2023.  When using the revised HS 200, the applicant will no longer need to submit the DHCS 6207 (for licensure disclosure purposes, however nothing will change for purposes of DHCS certification). However, if using the HS 200 dated (02/08) at the bottom of the form, the applicant will need to also submit the DHCS 6207.

The Centralized Applications Branch (CAB) will continue to accept the HS 200 dated (02/08) and the HS 215A dated (2/08) for applications submitted before December 31, 2023. Applications submitted January 1, 2024, and after must use the revised forms dated (Rev. 7/2023).

To access the revised versions of these forms, please visit the CDPH Licensing and Certification Program Forms webpage.

General Information

For questions concerning this AFL, please contact CAB by email at CAB@cdph.ca.gov or by phone at 916-552-8632.

Sincerely,

Original signed by Cassie Dunham

Cassie Dunham

Deputy Director

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