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.
Forms and Supporting Documents
Additional Instructions
(Each form listed also has instructions on the form)
Cover Letter
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, applicant contact email address)
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
[Title 42 Code of Federal Regulations (CFR) section 485.56]
A.10 – Certificate of Occupancy
[California Building Code (CBC) section 1226]
[42 CFR section 485.62(a)(1)]
For newly constructed or a remodeled building, the following is required:
New Certificate of Occupancy (CO) from the local building authority
Fire Safety Inspection Request
The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form
Control of Property
Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee
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
Noridian Healthcare Solutions Recommendation of Approval Letter
This letter is issued by Noridian Healthcare Solutions
The letter should be included with the application packet
CMS 359 (PDF)
Comprehensive Outpatient Rehab Facility Report
Submit the comprehensive outpatient rehab facility report for certifications
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