HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Chronic Dialysis Clinic

Report of Change Application Checklist for Change of Mailing Address

The following is a list of application forms and supporting documents required for a complete application packet. Failure to include each of the forms and documents will delay processing.

Checklist and Instructions - Please submit your documents in this order

Required Documents for a Change of Mailing Address

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

Cover Letter

Letter on company letterhead with the following information:

License number
Facility name and address
Facility ID number (if known)
Brief description of request
Applicant Contact Information (name, title, phone number, invoice contact email address, applicant contact email address)

The Department will use the invoice contact email address to invoice the application fee
The Department will use the applicant contact email address to send all application correspondence

General Contact Information (name, title, phone number, fax, email address, and alternative contact information)

The Department will use this information to contact the facility for day-to-day business

Emergency Contact Information (name, phone number, fax, email address, alternate email, and phone number that will receive text messages)

The Department will use this information to contact the provider in the event of an emergency using the California Health Alert Network (CAHAN). All information provided must allow CAHAN to contact the provider on a 24/7/365 basis for distribution of health alerts. For additional information: CAHAN (https://www.calhospitalprepare.org/cahan)

All Facility Letter Contact Information (name, phone number, fax, and email address)

The Department will use this information to send All Facility Letters

Facility Contact (Public Use) Information (phone number, fax, email address, and website address)

The Department will use this information to store facility contact information for the public

Privacy Officer Contact Information (name, title, mailing address, phone number, and email address)

The Department will use this information to correspond with the facility's Privacy/Compliance Officer regarding medical breach incidents

Signature

HS 200 (PDF, 1.5MB)

Licensure & Certification Application

Tip

Attachment F-1 — If the current or proposed facility, agency, or clinic is applying for Medi-Cal certification, complete Attachment F-1: Subcontractor Information and Significant Business Transactions

Medi-Cal Certification Documents

Forms and Supporting Documents

Additional Instructions
(Each form listed also has instructions on the form)

DHCS 9098 (PDF, 2.9MB)

Medi-Cal Provider Agreement

Do not leave any questions blank. Enter "same" or "N/A"
if not applicable
The mailing address must be the same as reported on the HS 200 form
Notarized signature page is required
Submit the "Acknowledgement" page from the notary public, if applicable

Medicare Certification Documents

Forms and Supporting Documents

Additional Instructions
(Each form listed also has instructions on the form)

CMS 855A (PDF)

Medicare General Enrollment Health Care Provider/Supplier Application

This application is from the Federal Department of Health and Human Services
The completed application should be mailed directly to the appropriate fiscal intermediary