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Phone: (916) 552-8632

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

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

Comprehensive Outpatient Rehabilitation Facility

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 License or CHOW 

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 (only applicable for CHOW)
  • 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 (
  • 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)

Licensure & Certification Application 
[Title 42 Code of Federal Regulations (42 CFR) 420 Subpart C,
and 455 Subpart B]
​Supporting Documents

A.10 Construction Documents

[42 CFR section 485.62(a)(1)]

If construction occurred and if the construction resulted in a new building or addition:

  • Submit a Certificate of Occupancy
  • This is not applicable if there were alterations or repairs to existing buildings performed or conversion of space

​Supporting Documents

B.3 Organizational Chart – Owner Type

[42 CFR section 485.56]

Submit an organizational chart if the owner is a for profit corporation, nonprofit corporation, limited liability company (LLC), or general partnership. The organizational chart needs to display the following:

  • Applicant’s owners, including ownership percentages, Tax IDs/EINs and all directors, board members, corporate officers, LLC, members/managers, and/or partners
    Note: Submit the HS 215A form for each of these individuals
  • Parent company of applicant, if applicable, and all of the licensed agencies/facilities it is operating- see B.6
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 485.56]

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

HS 215A (PDF)​

Applicant Individual Information

[42 CFR sections 420.206 subdivision (a)(3), 455.104, 485.56]

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

  • Administrator of the facility
  • Owners, directors, board members, corporate officers (Chief Executive Officer, President, Chief Operating Officer, Chief Financial Officer), 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
  • 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 

A resume is required for the Administrator, and Medical Director​

​Supporting Documents 
Professional Licenses/ Certificates

[42 CFR 485.70(a)(1)]

  • An active registered medical license is required for the Medical Director
  • ​Provide a printout of the current license from the Department of Consumer Affairs (

HS 309 1st Page​ (PDF)

Administrative Organization

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

HS 309 2nd Page​ (PDF)

Organizational Structure 

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


  • Page 2, item 1 — Health care districts will fill in the circle for other

Fire Safety Inspection Request

[42 CFR section 485.62(a)(1)]

The STD 850 form is required. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form

  • This form is not required for a CHOW unless there has been construction and/or remodeling
  • 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

​​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) ​

CMS 359 (PDF) 

Comprehensive Outpatient Rehab Facility Report

Submit the comprehensive outpatient rehab facility report for certifications

CMS 1561 (PDF) 

Health Insurance Benefits Agreement

Submit two (2) signed forms 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 B”
CMS 855B (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 intermedi​ary 
​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
HS 328 (PDF)

Notice ​– Effective Date of Provider Agreement
HHS 690 (PDF)

Assurance of Compliance

  • The Office of Civil Rights (OCR) online portal is: Office for Civil Rights (​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

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