HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Contact Us

Phone: (916) 552-8632
Email: CAB@cdph.ca.gov

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

Ambulatory Surgery Center

Report of Change Application Checklist for Change of Location

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.

Checklist and Instructions - Please submit your documents in this order

Required Documents for a Change of Location

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: Licensee physical address Facility name and address Facility ID number (if known) Brief description of request Previous and proposed/new location 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 (https://www.calhospitalprepare.org/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
STD 850 (PDF)	Fire Safety Inspection Request [Health and Safety Code (HSC) section 1226(f)] The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form
Supporting Documents	Control of Property Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee

Required Documents for Medicare Provider Only

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
CMS 855B (PDF)	Medicare General Enrollment Health Care Provider/ Supplier Application This application is from the Federal Department of Health and Human Services The completed application should be mailed directly to the appropriate fiscal intermediary
Supporting Documents	Noridian Healthcare Solutions Recommendation of Approval Letter This letter is issued by Noridian Healthcare Solutions after validation of the CMS 855B Medicare enrollment application The letter should be included with the application packet

Required Documents for Medi-Cal Provider Only

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
HS 200 (PDF, 1.5MB)	Licensure & Certification Application Tip 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 – Construction Documents [HSC section 1226.5] If construction occurred and if the construction resulted in a new building or addition: Submit a Certificate of Occupancy
Supporting Documents	D.1 – Control of Property Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee.
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 Notarized signature page is required Submit the “Acknowledgement” page from the notary public, if applicable

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