Primary Care Clinic
Initial Application Packet

A State license is required to operate a “community” or “free” Primary Care Clinic (PCC) in California, which are defined as:

A community clinic is “a clinic operated by a tax-exempt nonprofit corporation that is supported and maintained in whole or in part by donations, bequests, gifts, grants, government funds or contributions that may be in the form of money goods, or services. In a community clinic, any charges to the patient shall be based on the patient's ability to pay, utilizing a sliding scale,” pursuant to Health and Safety Code (HSC) section 1204(a)(1)(A).

A free clinic is “​a clinic operated by a tax-exempt nonprofit corporation supported in whole or in part by voluntary donations, bequests, gifts, grants, government funds or contributions that may be in the form of money, goods, or services. In a free clinic there shall be no charges directly to the patient for services rendered or for drugs, medicines, appliances, or apparatuses furnished,” pursuant to HSC section 1204(a)(1)(B).

To apply for an Initial license, you must complete the required application packet. Refer to HSC sections 1200 through 1245 for information regarding licensure requirements.

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. 

Please refer to the following links to get started:

• Provider Instructions (PDF)
• Provider Checklist ​
  

Application Packet Forms

• HS 200 - Licensure and Certification Application (PDF, 1.5MB)
  
• CDPH 270 - Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital (PDF) 
  
• HS 215A - Applicant Individual Information (PDF)
• HS 309 - Administrative Organization and Organizational Structure (PDF)
  
• HS 269 - Primary Care Clinic Provider Medi-Cal Certification Application (PDF) 
  
• STD 850 - Fire Safety Inspection Request (PDF)
  
• DHCS 9098 - Medi-Cal Provider Agreement​ (PDF)
  
• HS 328 - Notice of Effective Date of Provider Agreement (PDF)
  
• CMS 855B - 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