Surgical Clinic and Ambulatory Surgery Center
Initial Application Packet

A State license is required to operate a surgical clinic (SURGC) in California. A SURGC means “a clinic that is not part of a hospital and that provides ambulatory surgical care for patients who remain less than 24 hours. A surgical clinic does not include any place or establishment owned or leased and operated as a clinic or office by one or more physicians or dentists in individual or group practice, regardless of the name used publicly to identify the place or establishment, provided, however, that physicians or dentists may, at their option, apply for licensure,” pursuant to  Health and Safety Code (HSC) section 1204(b)(1). A SURGC may also apply for certification as an ambulatory surgery center (ASC). An ASC means “any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following an admission,” pursuant to Title 42 Code of Federal Regulations (CFR) section 416.2.

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. Refer to 42 CFR Part 416 for information regarding certification 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 (PDF)
• STD 850 – Fire Safety Inspection Request (PDF)
• HS 328 - Notice-Effective Date of Provider Agreement (PDF)
• CMS 855B - Medi-CalEnrollment Application​ (PDF)
  
• CMS 370 - Health Insurance Benefits Agreement (PDF)
  
• CMS 377 - Ambulatory Surgical Center Request for Initial Certification​ (PDF) 
  
• DHCS 9098 - Medi-Cal Provider Agreement​ (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