General Acute Care Hospitals and Acute Psychiatric Hospitals
Initial Application
Required Documents
Online Application PDF Form
- Embedded and generated by online system
Licensee/Business Entity Information
- āOrganizational chart displaying the following information: applicantās owners, directors, board members, corporate officers, LLC members/managers, and partners.
- āāThe 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
- āāFiling 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
- āList of Board of Directorsāā
Facility Director of Nursing
- āResume for the Director of Nursing
āFacility Property Information - Onsite
- āCopy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee
- āāDepartment of Health Care Access and Information (HCAI) Certificate of Occupancy (CO), Construction Final (CF), or Substantial Completion (SC)
- STD 850 (PDF) form - Fire Safety Inspection Requestā or a document that contains the fire inspectorās 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)
- āāCopy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee
- āāCDPH 270ā (PDF) form - Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital
- STD 850 (PDF) form - Fire Safety Inspection Requestā or a document that contains the fire inspectorās contact information (name, email, and address)
- Floor plan that includes a schematic of the room(s)
Mobile Units (Only applicable for addition of mobile units)
- Documentation/letter approval from the local planning/zoning agencyā
- 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) ā
- 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 āInspection Approvalāā
- STD 850ā (PDF) form - Fire Safety Inspection Requestā or a document that contains the fire inspectorās contact information (name, email, and address)ā
- Schematic displaying the location of the mobile unit on the facility propertyā
Patient Money Affidavit (Only required when applicable)
- HS 402 (PDF) āform - Surety Bond Verification
- HS 400 (PDF) form - Affidavit Regarding Patient Money
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/responsibilitiesā
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 - Health Insurance Benefit Agreement
- DHCS 6207 ā(PDF) form - Notice-Effective Date of Provider Agreement
- One of the following Internal Revenue Service tax documents:
- Form 941 - Employerās 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 Agreementā