End-Stage Renal Disease Dialysis Facility
Change of Governing Board Application Packet

A dialysis clinic may be certified as en End-Stage Renal Disease (ESRD) facility in California. An ESRD facility is an entity that provides outpatient maintenance dialysis services, or home dialysis training and support services, or both, pursuant to Title 42 Code of Federal Regulations (CFR) section 494.10. 

To report a Change of Governing Board, you must complete the required application packet. Refer to 42 CFR Part 494, Subpart A for the Conditions For Coverage For End-Stage Renal Disease Facilities regarding certififcations 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 certification. 

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)​
  

• HS 215A – Applicant Individual Information (PDF)
  

• HS 309 – Administrative Organization (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​