Home Health Agency 
Branch Office Application Packet

A State license is required to operate as a Home Health Agency (HHA) Branch Office in California. An HHA Branch Office means "a home health agency established and administered by a parent home health agency, providing services within a portion of the total service area served by the parent agency. Patients are accepted for service by the branch office at a separate location from the parent agency. The branch office is not required to be staffed with an Administrator and a Director of Patient Care Services but must have a Nurse Supervisor available on the premises or immediately accessible by telecommunications during operating hours when patients are receiving services. The parent agency shall develop and implement a written plan for administration and supervision of a branch office. The administration at the parent agency shall be responsible for the staffing, patient census, and any issues affecting the operation of a given branch", pursuant to Title 22 of the California Code of Regulations (CCR) section 74609.

To apply for an HHA Branch​​ Off​ice license, you must complete the required application packet.

How to Apply

An applicant must submit a completed application packet to the Centralized Applications Branch (CAB). The application packet contains the required forms in one location. The provider checklist identifies the required forms and supporting documents needed to apply for licensing and certification. The provider instructions are a resource to guide you through the process. The Sample Application Packet is a visual aid that displays a sample of the completed forms contained in the application packet.

Please refer to the following links to get started:

• Provider Instructions (PDF)
• Provider Checklist
  

Applicatio​​n Packet Forms

• ​HS 200 - Licensure and Certification Application (PDF, 1.5MB)
  
• CMS 1572 - Home Health Agency Survey and Deficiency Report​ (PDF)
  
• 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
          Licensing and Certification Program
          Centralized Applications Branch
          P.O. Box 997377, MS 3207
          Sacramento, CA 95899-7377