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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​​​​​​​​​

Ambulatory Surgery Center

Report of Change Application Checklist for Change of Service

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 - P​lease submit your documents in this order

Required Documents for a Change of Service

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:

  • Facility name and address
  • Facility ID number (if known)
  • Brief description of request
  • Include service(s) adding or removing
  • 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, 1.5MB)

Licensure & Certification Application


  • 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

Note: Not applicable to Medicare providers

​Supporting Documents 

A.10 – Certificate of Occupancy

[24 CCR section Part 2 section III]

[Title 42 Code of Federal Regulations (CFR) section 416.44]

If construction occurred and if the construction resulted in a new building or addition:

  • Submit a Certificate of Occupancy
STD 850 (PDF)

Fire Safety Inspection Request

[Health and Safety Code (HSC) section 1226(f)]

[24 CCR Part 9 section]                          ​

If construction occurred:

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

Medicare Certification Documents 
​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
  • The letter should be included with the application packet
​CMS 377 (PDF) 
Ambulatory Surgical Center Request for Initial Certification
  • Submit one copy of the CMS 377 form

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