Home Health Agency
Change of Certification Application Packet

A State license is required to operate as a Home Health Agency (HHA) in California. An HHA means “a private or public organization, including but not limited to, any partnership, corporation, political subdivision of the state, or other government agency within the state, which provides, or arranges for the provision of, skilled nursing services, to persons in their temporary or permanent place of residence,” pursuant to Title 22 of the California Code of Regulations (CCR) section 74600(a).​

To apply for Medi-Cal and/or Medicare certification to a licensed health facility, 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 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
  
• Provide​r Checklist
  

Application​ Packet Forms

• HS 200 - Licensure and Certification Application (PDF, 1.5MB)
• DHCS 9098 - Medi-Cal Provider Agreement (PDF)​
• HS 328 - Notice of Effective Date of Provider Agreement (PDF)​​
• CMS 855A ​-  ​Medicare Enrollment Application (Institutional​ Providers)​​​​ (PDF)
  
• CMS 1561​ - Health Insurance Benefit Agreement​​ (PDF)
• CMS 1572A - HHA Survey and Deficiency Report​ (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