End-Stage Renal Disease Dialysis Facility
Change of Name Application Packet

A dialysis clinic may be certified as an 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 Name, 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 certification 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)​
  

• CMS 855A - Medi-Cal Enrollment Application/Supplier Application​ (PDF)
  

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

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