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HEALTH CARE FACILITY LICENSING AND CERTIFICATION​​

 Contact Us

Phone: (916) 552-8632
Email: CAB@cdph.ca.gov    

For application status requests, please include the following in your email:

  • Name of Facility or Agency
  • License or Facility/Agency # (if applicable)
  • Address
  • Facility or Provider Type
  • Date Documentation Sent
  • Contact Number​​​​

Community Mental Health Center 

Initial and Change of Ownership Application Checklist 

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.

  • Initial License
  • Change of Ownership (CHOW)
  • Medicare

Checklist and Instructions - P​lease submit your documents in this order

Required Documents for an Initial or CHOW 

Forms and Supporting​​ Docume​​nts​​

​​Additional Instructions

(​​​Each form listed also has instructions on the form)​

​Cover Letter

Cover Letter

Letter on company letterhead with the following information:

  • Facility name and address
  • Facility ID number (if known)
  • Brief description of request
  • Contact information (name, title, phone number, and e- mail address)
  • Emergency Contact Information (name, email, alternate email, phone, fax, 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​)
  • Contact Information for the Privacy Officer or Designee responsible for submitting and responding to medical breach incidents (name, title/position, mailing address, phone number, and email address)
  • Signature
HS 200 (PDF, 1.5MB)

Licensu​re & Certification Application

​Supporting Documents 

B.3  Non-Profit Status – Owner Type

Submit a copy of the IRS Tax Exempt Determination Letter showing the non-profit 501(c)(3) status. (If applicable)

​Supporting Documents
B.4.b – License Revocation (if applicable)
Submit additional information, including all ownership and facility information, date and any final action
​Supporting Documents 

B.6  Organizational Chart

[42 CFR section 485.918(a)(1)]

If licensee is a subsidiary of another organization, an organizational chart must be submitted
Supporting Documents

​D.1 – Control of Property​

[42 CFR section 485.918(a)(1)]

Submit a copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed Licensee

HS 215A (PDF)​

Applicant Individual Information

[42 CFR section 420.206, 485.904(b)(1), 485.918(a)]

This form must be completed and signed for the following individuals:

  • Administrator of the facility
  • Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization
  • Owners, directors, board members, corporate officers, LLC members/managers, and partners of the parent, grandparent, great grandparent, and etc. organization, if applicable
  • Each individual having a beneficial interest of exceeding five percent or more in the applicant organization and/or parent, grandparent, great grandparent, and etc. organization 
​Tips
  • Page 2, section B — The date of birth is an identifier, as several people may have the same name. This will ensure that each individual is associated with the correct facility or entity
  • Page 5, section E — Submit ten years of employment history, indicating the start and end dates of employment, job title, employer name and address. The applicant may submit a resume in lieu of completing section E; however, the resume must contain all required information requested in section E
  • Page 7, section F If answering yes to any question in this section, complete Section H: Facility Information Sheet
​Supporting Documents
Facility Information Sheet​

Each individual must complete and submit the Facility Information Sheet for each facility and/or agency with which the individual has a current or past relationship within the last three years. This sheet must also include any facilities licensed by the California Department of Social Services. The following must be completed for each facility and/or agency:

  • Facility name
  • Facility address
  • Type of facility
  • Type of business entity (include EIN Number)
  • Individual's nature of involvement
  • Individual's dates of involvement
​Supporting Documents 

Resume

A resume is required for the Administrator

HS 309 1st Page​ (PDF)


Administrative Organization

Along with the HS 309, the following supporting documents according to organizational type must be submitted:

Supporting Documents​

Corporation

  • Filing Statement from the Secretary of State
  • Articles of Incorporation
  • By-Laws 
  • List of Board of Directors (only if additional space is needed to input all board of directors)
Tip
  • Page 1, item 3 — The incorporation date is located in the top right corner of the applicant Articles of Incorporation
​Supporting Documents 
Limited Liability Company (LLC)
  • Filing Statement from the Secretary of State
  • Articles of Organization
  • Operating Agreement
  • List of Managing Members (only if additional space is needed to input all managing members)

HS 309 2nd Page​ (PDF)


Organizational Structure

Only complete fields that are applicable to applicant's entity type


​​Required Documents for a CHOW Only​

Forms and Supporting Documents​​​

Additional Instructions

(Each form listed also has instructions on the form) ​

Supporting Docum​​ents

In addition to the forms required for an Initial application listed above submit the documents requested below:

  • Copy of Purchase Agreement or Operating Transfer Agreement
  • Copy of Interim Management Agreement (If applicable)
  • A letter from the prospective licensee (to CDPH) stating where the stored patient medical records will be maintained, and that the records will be made available to the previous licensee​

Medicare Certification Documents 

Forms and Supporting Documents​​​

Additional Instructions

(Each form listed also has instructions on the form) ​

​Exihibit 131 (PDF)
​Community Mental Health Center Crucial Data Extract
Exhibit 275 (PDF)
​Attestation Statement
Exhibit 282​ (PDF)
​Model Letter Participation In Medicare As A Cmhc Providing Partial Hospitalizing Services
CMS 1561 (PDF) 

Health Insurance Benefits Agreement

Submit two (2) signed copies with “original" signatures:

  • Initial Application: Sign the top signature block entitled “Accepted for the Provider of Services By"
  • CHOW: Sign the bottom signature block entitled “Accepted for the Successor Provider of Services By"
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​
​Supporting Documents 
Noridian Healthcare Solutions Recommendation of Approval Letter
  • This letter is issued by Noridian Healthcare Solutions
  • The letter should be included with the application packet
HHS 690 (PDF)

Assurance of Compliance​

  • The Office of Civil Rights (OCR) online portal is: Office for Civil Rights (https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf)
  • Once the online submission is completed, an electronic notification from OCR stating the Assurance of Compliance form was submitted successfully will be received by the applicant
  • Submit a copy of this notification
HS 328 (PDF) 

Notice – Effective Date of Provider Agreement


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