Alternative Birth Center
Change of Certification Application Packet

A State license is required to operate an Alternative Birth Center (ABC) in California. An ABC means “a clinic that is not part of a hospital and that provides comprehensive perinatal services and delivery care to pregnant women who remain less than 24 hours at the facility,” pursuant to Health and Safety Code (HSC) section 1204(b)(4).

To apply for Medi-Cal and/or Medicare certification to a licensed health facility, you must complete the required application packe​t. 

How to Apply

An applicant must submit a completed application packet to the Centralized Applications Branch (CAB). The provider instructions are a resource to guide you through the process. The provider checklist identifies the required forms and supporting documents needed to apply for licensing. 

Please refer to the following links to get started:

• Provider Instructions
  
• Provider Checklist
  

Application Packet Forms

• HS 200 - Licensure and Certification Application  (PDF, 1.5MB)
• DHCS 1051 - Civil Rights Compliance Review (PDF)
• DHCS 9098 - Medi-Cal Provider Agreement (PDF)
  
• HS 328 - Notice of Effective Date of Provider Agreement (PDF)
• CMS 855B  - Medicare Enrollment Application​ (PDF)
  
• CMS 1561 - Health Insurance Benefit Agreement (PDF)
  
• HHS 690 - Assurance of Compliance (PDF)
  

Where to Submit Applications

Submit completed application packets to the CAB at the address listed below. Do not send any completed application packets, forms, or supporting documents to the local CDPH, District Office.

          California Department of Public Health
          Licensing and Certification Division
          Centralized Applications Branch
          P.O. Box 997377, MS 3207
          Sacramento, CA 95899-7377​