Online Application PDF Form
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Licensee/Business Entity Information
Organizational chart displaying the following information: applicant’s owners, directors, board members, corporate officers, LLC members/managers, and partners.
The organization chart needs to include all entities that have 5% or more direct and indirect ownership
Foreign or out of state corporations, LLCs, and partnerships need to submit Certificate of Qualifications from the California Secretary of State
Entity Organization
Filing Statement from the Secretary of State
Please submit the following documents based on the applicable ownership type:
Corporation - Submit Articles of Incorporation and By-Laws
LLC - Submit Articles of Organization and Operating Agreement
Public Agency - Submit Copy of signed Resolution
Partnership - Submit Copy of signed Partnership Agreement
List of Board of Directors
Facility Director of Nursing
Resume for the Director of Nursing
Facility Property Information - Onsite
Copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee
Department of Health Care Access and Information (HCAI) Certificate of Occupancy (CO), Construction Final (CF), or Substantial Completion (SC)
STD 850 – Fire Safety Inspection Request (PDF) or a document that contains the fire inspector’s contact information (name, email, and address)
Floor plan that includes a schematic of the room(s)
Facility Property Information - Offsite (Only applicable for addition of offsite services)
Copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee
CDPH 270 – Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital (PDF)
Mobile Units (Only applicable for addition of mobile units)
Documentation/letter approval from the local planning/zoning agency
Department of Health Care Access and Information (HCAI) Certificate of Occupancy (CO), Construction Final (CF), or Substantial Completion (SC)
Letter verifying the mobile unit is self-contained (only when applicable)
Copy of vehicle registration, including ID, vehicle type and manufacturer (Not applicable for modular units)
Copy of Department of Housing & Community Development (HCD) Insignia or “Inspection Approval”
STD 850 – Fire Safety Inspection Request (PDF) or a document that contains the fire inspector’s contact information (name, email, and address)
Schematic displaying the location of the mobile unit on the facility property
Patient Money Affidavit (Only required when applicable)
HS 400 – Affidavit Regarding Patient Money (PDF)
HS 402 – Surety Bond Verification (PDF)
Subcontractor Information (Only Required when applicable)
Copy of any written agreement(s) that Licensee/Business Entity has with the subcontractor that relate to its functions/responsibilities
Facility Information - Medicare Certification Documents (Only applicable for Medicare Certification)
CMS 1561 – Health Insurance Benefit Agreement (PDF)
HS 328 – Notice Effective Date of Provider Agreement (PDF)
HHS 690 – Assurance of Compliance (PDF) 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 – Medi-Cal Provider Agreement (PDF, 2.9MB)
DHCS 6207 – Medi-Cal Disclosure Statement (PDF)
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