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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

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)
  • 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)
  • 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
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 Supportin​​g Documents​​

​​Additional Instructions

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

​​HS 200 (PDF)

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 Docum​​ents
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 (CO)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


Required Documents for Medicare for Certification

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form) 




  • Notarized signature page is required
  • Submit the “Acknowledgement” page from the notary public
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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