Application Request for a Chronic Dialysis Clinic
(End-stage Renal Disease Facility)
These instructions are to assist you in preparing a chronic dialysis clinic (CDC) licensing and/or certification (for Medi-Cal Title 19 and/or Medicare Title 18 reimbursement) application package to the California Department of Public Health (CDPH), Licensing and Certification (L&C) Program. When preparing your application package, please use the following applicable checklist(s):
A state license is required to operate as a CDC in California, which is defined as:
Chronic dialysis clinic means a "free-standing specialty clinic, which provides less than 24-hour care for the treatment of patients with End-Stage Renal Disease."
An application package is required for: (1) a new (initial) CDC and (2) whenever a CHOW occurs. A CHOW is the only "change" requiring a new application package to be submitted to L&C’s Centralized Applications Branch (CAB). The other changes do not require submittal of a new application package. CAB will assist you on which forms on the checklist must be submitted for the specific change to the license.
Completion of Applications
For your convenience, each checklist has instructions to complete the forms required for licensing and certification of a CDC. The checklist provides specific item numbers that applicants typically have encountered problems in submitting incorrect or missing information. Please make sure that all item numbers in each form are completely filled out. For example: (1) the applicant’s formal name must be consistently the same throughout all the documents in the application package; or (2) in some instances, a specific attachment may need to be submitted with a specific form. All forms are required to be signed by the "licensee," owners, or officers, unless otherwise stated.
Please read each required application package form carefully and provide all requested supplemental documents. Use the guidance below:
- Do not leave any items blank.
- If a question does not apply, please respond with "Not Applicable" or "N/A."
- Do not make changes to these forms.
- Use "blue" ink to sign all forms.
- Do not use white out/correction fluid to make corrections.
- To correct an error, place a single line through the entry and enter the correct information. The individual responsible for making the correction must initial and date the correction.
- There are some differences between documents required for a CHOW and "initial" applications that are noted on the checklist.
You should retain a photocopy of the completed documents for your files. We may need to contact you in the future and we will be referring to the information in the documents you provided.
Submission of Applications
All completed application packages must be submitted to CAB via regular mail to:
California Department of Public Health
Licensing and Certification Program
Centralized Applications Branch
P.O. Box 997377, MS 3207
Sacramento, CA 95899-7377
CAB will review the application package for completion. Once the application package has been given a recommendation of "approved" by CAB and all required surveys have been performed, CAB will issue the license accordingly.
In addition, a check or money order made payable to the "California Department of Public Health" for the licensing fee, determined pursuant to H&S Code Section 1266, must accompany the required forms before your application will be processed. The licensing fees change annually; therefore, please check the current licensing fee for a CDC which is posted on the L&C Facility Fee website.
The application fee will not be returned if the application is withdrawn or denied.
The application package review process will consider the applicant’s and associates’ (i.e., board members, LLC members, managers, etc.) past compliance history. This will be based on a review of all facilities and agencies operated by those individuals in California and nationally. The applicant and associates must demonstrate substantial compliance with state and federal requirements for all facilities that they operate, pursuant to H&S Code Section 1755.
Failure to demonstrate substantial compliance history may result in the denial of your application package. You will be notified in writing of L&C’s intent to deny the application.
National Provider Identifier
To apply for National Provider Identifier (NPI), go to the National Plan and Provider Enumeration System website.
Initial Licensing Survey
An initial licensing survey is part of the application process for "initial" or "new" CDC applications. The initial licensing survey is a scheduled survey conducted by L&C DOs. You are required to be licensed prior to seeking certification status.
Except for the Los Angeles (LA) facilities, the DO will notify you (via letter) when the application has been approved by CAB and will schedule an "initial" licensing survey. For the LA facilities, the CAU will notify you (via letter) when the application has been approved and will schedule an "initial" licensing survey.
Note: You must be ready for the initial licensing survey upon notification. It is L&C’s policy that, except for very unusual circumstances, only one inspection visit will be made. Failure of the facility to be in substantial compliance, at the time of the visit, will result in the "denial" of the application. Any further activity regarding your request, after such denial, will require a new application, and license fee.
Please note: An "initial" license will not be issued until the application is approved and, if required, a successful licensing survey is conducted.
If your facility wants to provide services to Medicare beneficiaries (under Title 18) and Medi-Cal beneficiaries (under Title 19), you will need an additional certification survey that is unannounced and conducted by one of our L&C DOs. If you want the L&C DO to conduct the "initial" certification survey, submit justification to the DO for Centers for Medicare & Medicaid Services approval.
In addition, you must be in compliance with state licensing laws and federal conditions of participation.
If you have any questions, please contact the CAB, at (916) 552-8632 or by e-mail at CAB@cdph.ca.gov.