General Acute Care Hospitals and Acute Psychiatric Hospitals
Change of Services - Offsite
Required Documents
Online Application PDF Form
- Embedded and generated by online system
Addition, Expansion, or Reactivation of Services
- āCopy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee (Not required for reactivation)
- Certificate of Occupancy from the local building authority (Not required for reactivation)
- CDPH 270 (PDF) form - Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital
- STD 850 (PDF)āā form - Fire Safety Inspection Request or a document that contains the fire inspectorās contact information (name, email, and address)
- Floor plan that includes a schematic of the room(s)
Relocation of Services - Offsite Relocation
- āCopy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee
- Certificate of Occupancy from the local building authority
- CDPH 270 (PDF) form - Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital ā
- STD 850 (PDF)āā form - Fire Safety Inspection Request or a document that contains the fire inspectorās contact information (name, email, and address)
- Floor plan that includes a schematic of the room(s)
Relocation of Services - Offsite to an Onsite Location
- Department of Health Care Access and Information (HCAI) Certificate of Occupancy (CO), Construction Final (CF) or Substantial Completion (SC)
- Floor plan that includes a schematic of the room(s)
- STD 850ā (PDF) form - Fire Safety Inspection Request or a document that contains the fire inspectorās contact information (name, email, and address)
- Upon approval of the onsite services addition, submit a change of offsite services application to remove supplemental services from the offsite location
Helpful Tip:
āSuspension or Removal of a Supplemental Service
- Proof that the facility notified the California Department of Public Health (District Office) 180 days prior to the planned reduction or elimination of the level of emergency medical services, the notification of the intended change*
- Copy of the notice to the city council of the city in which the facility is located*
- Copy of the notice that was provided to the California Department of Public Health (District Office)*
- Proof of a notice posted in a conspicuous location on the home page of the facility's internet website*
- āProof of a notice published in a conspicuous location within a newspaper of general circulation serving the local geographical area in which the facility is located*
- Proof of a notice in a conspicuous location within the internet website of a newspaper of general circulation serving the local geographical area in which the facility is located*
- Proof of a notice posted at the entrance of every community clinic, within the affected county in which the facility is located, that grants voluntary permission for postingā
*Note: These reporting conditions do not apply to a facility forced to close or eliminate service as a result of a natural disaster or state of emergency that prevents the facility from operating at its full pre-emergency capacity.
(All Facilities Letter (AFL) 21-04)
Supplemental Service Outpatient Clinic Name Change
- āDHCS 9098 (PDF) form ā Medi-Cal Provider Agreement (Required if certification and billing is separate from the main facility)
Outpatient Rural Health Clinic (RHC)
- Copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee (Not required for reactivation)
- Certificate of Occupancy from the local building authority (Not required for reactivation)
- CDPH 270 (PDF) form - Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital ā
- DHCS 6207 (PDF) form ā Medi-Cal Disclosure Statement (Only submit Section V ā Subcontractor Information and Significant Business Transactions)
- STD 850 (PDF) form - Fire Safety Inspection Request or a document that contains the fire inspectorās contact information (name, email, and address)
- Floor plan that includes a schematic of the room(s)
- CMS 29 (PDF) form ā Verification of Clinic Data ā Rural Health Clinic Program
- HS 610ā (PDF) form ā Medically Underserved or Health Professional Shortage Areas
RHC 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 Agreementā
- HHS 690 (PDF) form - Assurance of Compliance (Submit a verification from the Office of Civil Rights displaying submission of this form)