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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health



Certification Request for a Rural Health Clinic (Non-Urbanized Area)

These instructions are to assist you in preparing a rural health clinic (RHC) certification (for Medi-Cal Title 19 and/or Medicare Title 18 reimbursement) package to the California Department of Public Health (CDPH), Licensing and Certification (L&C) Program. When preparing your certification package, please use the following applicable checklist(s):


Certification Requirements

Prior to submitting a RHC certification package, you must submit the following forms to the Centralized Applications Branch (CAB) to determine whether the location qualifies based on the census tract number:  

In order to be certified, the RHC must be located in an area that is not an urbanized area and in a medically underserved area (MUA) or health professional shortage (HPSA) area. The Centers for Medicare & Medicaid Services (CMS) will determine if the location qualifies and the Office of Statewide Health Planning and Development (OSHPD) will determine if it’s in a HPSA or MUA area. Once CAB is notified of the determination, CAB will notify you whether or not to submit a certification package.

An application package is required for: (1) a new (initial) RHC facility and (2) whenever a CHOW occurs. A CHOW is the only "change" requiring a new certification package to be submitted to CAB. The other changes do not require submittal of a new certification package. CAB will assist you on which forms on the checklist must be submitted for the specific change.

Note: If you are already licensed as a primary care clinic and want to be certified as a RHC, submit the certification forms to CAB.


Completion of Certification Package

For your convenience, each checklist has instructions to complete the forms required for certification of a RHC (non-urbanized area). 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 certification 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 Certification Package

 All completed RHC certification 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 certification package for completion. Once the certification package has been given a recommendation of "approved" by CAB and all required surveys have been performed, CAB will issue the license accordingly.


National Provider Identifier

To apply for National Provider Identifier (NPI), go to the National Plan and Provider Enumeration System website.


Certification Survey

For certification as a RHC who will provide services to Medicare beneficiaries (under Title 18) and Medi-Cal beneficiaries (under Title 19), you will need a certification survey that is unannounced and will be conducted by one of the L&C district offices. The survey will determine if you are in compliance with the federal requirements for a RHC.  


If you have any questions, please contact the CAB, at (916) 552-8632 or by e-mail at CAB@cdph.ca.gov.



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