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 Contact Us

Phone: (916) 552-8632

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

General Acute Care Hospitals and Acute Psychiatric Hospitals

Change of Certification

Required Documents

Online Application PDF Form
  • Embedded and generated by online system
Facility Information - Medicare Certification Documents (Only applicable for Medicare Certification) 
  • ​CMS 1561 (PDF) form - Health Insurance Benefit Agreement 
  • HS 328 (PDF) form - Notice-Effective Date of Provider Agreement 
  • HHS 690 (PDF) form - Assurance of Compliance (Submit a verification from the Office of Civil Rights displaying submission of this form)​
Facility Information - Medi-Cal Certification Documents (Only applicable for Medi-Cal Certification)​​
  • DHCS 9098 (PDF) form – Medi-Cal Provider Agreement 
  • DHCS 6207 (PDF) form – Medi-Cal Disclosure Statement (Only submit Section V – Subcontractor Information and Significant Business Transactions) 
  • One of the following Internal Revenue Service tax documents: ​
    • Form 941 – Employer’s Quarterly Federal Tax Return
    • Form 8109-C – FTD Address Change
    • Letter 147-C – EIN Verification Letter​
    • Form SS-4 – Application for Employer Identification Number
  • HS 328​ (PDF) form - Notice-Effective Date of Provider Agreement​​
Helpful Tips
  • ​Specify if the request is for the main or distinct part (D/P) facility or service.
  • Submit a Change of Mailing Address (CHMA) application(s) for the following:
    • ​​Facility mailing address changes.
    • Medi-Cal pay-to-address changes.
  • ​​Submit a Change of Certification (CHOC) application to add/remove Medi-Cal and/or Medicare certification.
  • Submit a Change of National Provider Identifier (CNPI) for NPI changes.
  • Submit a Change of Name (CHON) to update the legal or business name.​
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