HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Ambulatory Surgery 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 Certification
Change of Ownership (CHOW)
Medicare
Medi-Cal

Checklist and Instructions - Please submit your documents in this order

Required Documents for Initial Certification

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 Licensee (entity) physical address Facility ID number (if known) Brief description of request Explanation of licensure exemption status, based on Health and Safety Code 1206 (ASC may be required to be licensed as a surgical clinic) Applicant Contact Information (name, title, phone number, invoice contact email address, applicant contact email address) The Department will use the invoice contact email address to invoice the application fee The Department will use the applicant contact email address to send all application correspondence General Contact Information (name, title, phone number, fax, email address, and alternative contact information) The Department will use this information to contact the facility for day-to-day business Emergency Contact Information (name, phone number, fax, email address, alternate email, 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) All Facility Letter Contact Information (name, phone number, fax, and email address) The Department will use this information to send All Facility Letters Facility Contact (Public Use) Information (phone number, fax, email address, and website address) The Department will use this information to store facility contact information for the public Privacy Officer Contact Information (name, title, mailing address, phone number, and email address) The Department will use this information to correspond with the facility's Privacy/Compliance Officer regarding medical breach incidents Signature
Supporting Documents	B.3 – Organizational Chart – Owner Type Submit an organizational chart if the owner is a for-profit corporation, nonprofit corporation, limited liability company (LLC), or general partnership. The organizational chart needs to display the following: Applicant’s direct and indirect owners, including ownership percentages, TAX IDs/EINs and all directors, board members, corporate officers, LLC members/managers, and/or 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 Management company of applicant, if applicable, and all of their facilities
Supporting Documents	B.6 – Organizational Chart If direct owner is a subsidiary of another organization, an organizational chart must be submitted
HS 309 1st Page (PDF)	Administrative Organization Along with the HS 309, the following supporting documents according to organizational type must be submitted:
Supporting Documents	Corporation (if applicable) Filing Statement from the Secretary of State Articles of Incorporation By-Laws List of Board of Directors (only if additional space is needed to input all board of directors) A copy of the Resolution authorizing the filing of the application A copy of authorization of a foreign (out of state) corporation to do business in California Tips Page 1, item 3 — The incorporation date is located in the top right corner of the applicant Articles of Incorporation In addition to this page, corporations are required to complete item 5 on page 2
Supporting Documents	Limited Liability Company (LLC) Filing Statement from the Secretary of State Articles of Organization LLC Operating Agreement List of Managing Members (only if additional space is needed to input all managing members) A copy of the Resolution authorizing the filing of the application A copy of authorization of a foreign (out of state) corporation to do business in California Tips Page 1, item 3 — The incorporation date is located in the top right corner of the Articles of Organization Ensure the operating agreement identifies the Capital Contributions, which lists each individual and/or entity that is contributing to the LLC
HS 309 2nd Page (PDF)	Organizational Structure Only complete fields that are applicable to applicant’s entity type Tip Page 2, item 1 — Health care districts will fill in the circle for other
HS 602 (PDF)	Transfer Agreement [Title 42 Code of Federal Regulations (CFR) section 416.41(b)] Copy of current written transfer agreement with a General Acute Care Hospital and the facility that meets the requirements of the Code of Federal Regulations Tip The Facility Administrator has the authority to sign this form The facility may not have a Facility Provider Number yet, and may be left blank

Required Documents for Medi-Cal Certification

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 (not applicable for a CHOW) [California Health and Safety Code (HSC) section 1226.5] If Yes, submit the new Certificate of Occupancy from the local building authority If No, submit the most recent CO (N/A for CHOW)
Supporting Documents	B.4.b - Revocation (if applicable) Submit additional information, including all ownership and facility information, date and any final action
Supporting Documents	B.3 – Internal Revenue Service Documentation [Title 42 CFR section 455.104(b)(1)(iii)] Submit one of the following IRS tax documents showing the 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	C.1.a – Management Company Agreement (If applicable) Facilities operated under a Management Agreement between the entity and a management company must complete and submit Attachment E-1 (Management Company Information) and submit a copy of the Management Agreement The Management Agreement must state that the entity is responsible for the Facility
Supporting Documents	D.1 - Control of Property Submit a copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed entity
Supporting Documents	Floor Plan Submit a floor plan that coincides with your office space
HS 215A (PDF)	Applicant Individual Information [Title 42 CFR section 455 Subpart B] This form must be completed for the following individuals: Administrator of the facility Applicant Organization Owners, directors, board members, corporate officers, LLC members/managers, partners, and/or trustees of the applicant organization and/or Management Company Each individual having a direct or indirect beneficial interest of five percent or more in the applicant organization and/or parent company Tips 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	Public Agency Copy of signed Resolution
Supporting Documents	Partnership Copy of signed Partnership Agreement
STD 850 (PDF)	Fire Safety Inspection Request (not applicable for a CHOW and for facilities that are currently Medicare certified) [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.
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

Required Documents for Medicare for Certification

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
CMS 370 (PDF)	Health Insurance Benefits Agreement Submit 2 copies of the CMS 370 form with original signatures
CMS 377 (PDF)	Ambulatory Surgical Center Request for Initial Certification Submit one copy of the CMS 377 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

Required Documents for a CHOW

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

Supporting Documents

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

Copy of Purchase Agreement or Operating Transfer Agreement

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