Chronic Dialysis Clinic 
Change of Mailing Address Application Packet

A State license is required to operate a Chronic Dialysis Clinic (CDC) in California. A CDC means "a clinic that provides less than 24-hour care for the treatment of patients with end-stage renal disease, including renal dialysis services," pursuant to Health and Safety Code (HSC) section 1204(b)(2).

To report a Change of Mailing Address, you must complete the required application packet. Refer to HSC sections 1200 through 1245 for information regarding licen​​sure requirements.

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 licensure. 

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 9098 - Medi-Cal Provider Agreement (PDF, 2.9MB)​

• CMS 855A - Medicare General Enrollment Health Care Provider/Supplier Application (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
          Center for Health Care Quality
          Centralized Applications Branch
          P.O. Box 997377, MS 3207
          Sacramento, CA 95899-7377​