HEALTH CARE FACILITY LICENSING AND CERTIFICATION

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

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

End-Stage Renal Disease Clinic

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
Medi-Cal

Checklist and Instructions - Please 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 (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)	Licensure & Certification Application [Title 42 Code of Federal Regulations (42 CFR) section 420 Subpart C and 455 Subpart B] 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
Supporting Documents	B.3 – Organizational Chart – Owner Type [42 CFR section 494.180] 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/EIN and all directors, board members, corporate officers, LLC members/managers, and/or partners Note: Submit the HS 215A form for each of these individuals Management company of applicant, if applicable, and all of their facilities Parent company of applicant, if applicable, and all of the licensed agencies/facilities they are operating- see B.6
Supporting Documents	B.3 – Non-Profit – 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.6 – Organizational Chart [42 CFR section 494.180] If licensee is a subsidiary of another organization, include an organizational chart
Supporting Documents	Floor Plan [HSC section 1212(a)(9)] Submit a floor plan that coincides with your office space
HS 215A (PDF)	Applicant Individual Information [42 CFR sections 420.206(a)(3), 455.104, 494.140 subdivisions (a) and (b)(1), and 494.180 subdivisions (a), (b) and (j)] This form must be completed for the following individuals: Administrator of the facility, the Director of Nursing, and the Medical Director 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 [42 CFR 494.140 (a)(1), 494.140 (b)(1)(iii)] A resume is only required for the Administrator(s), Director of Nursing, and Medical Director
Supporting Documents	Professional Licenses/ Certificates [HSC sections 1212(a)] [42 CFR 494.140 subdivisions (a) and (b)] An active registered medical license is required for the Medical Director and Director of Nursing Provide a printout of the current license from the Department of Consumer Affairs (https://search.dca.ca.gov/)
HS 309 1st Page (PDF)	Administrative Organization [42 CFR 494.180] Corporations complete page one Do not submit any attachments
HS 309 2nd Page (PDF)	Organizational Structure Only complete fields that are applicable to applicant’s entity type
HS 602 (PDF)	Transfer Agreement [42 CFR 494.180(g)(3)] Copy of current (within one year of submission of application) written transfer agreement with hospital appropriate to meet medical emergencies
STD 850 (PDF)	Fire Safety Inspection Request [42 CFR 494.60 (d)(3)] 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 Documents

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
A letter from the prospective licensee (to CDPH) stating the location where the stored patient medical records will be maintained, and affirming that the records will be made available to the previous licensee
Copy of “Interim Management Agreement” (if applicable)

Medi-Cal Certification Documents

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

DHCS 9098 (PDF)

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, section C, Page 8, item 3.c.1
Notarized signature page is required
Submit the "Acknowledgement” page from the notary public, if applicable

HS 328 (PDF)

Notice- Effective Date of Provider Agreement

If applying for both Medi-Cal and Medicare certification, only submit one copy of this form

Medicare Certification Documents

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
Business Plan Letter	Business Plan Letter Letter explaining in detail the Business Plan for operation of the ESRD, including a description of all services to be provided
CMS 855B (PDF)	Medicare General Enrollment Health Care Provider/ Supplier Application This application is from the U.S. 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
CMS 3427 (PDF)	End Renal Disease Application/ Notification and Survey and Certification Report [State Operation Manual 2274B] Items 1-24 must be completed with applicable information. The surveyor will bring a copy of the form to update and add information when the certification survey is conducted
HS 328 (PDF)	Notice – Effective Date of Provider Agreement If applying for both Medi-Cal & Medicare certification, only submit one copy of this form

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