Skip Navigation LinksHHA-CGSA-Provider-Checklist

HEALTH CARE FACILITY LICENSING AND CERTIFICATION​​​​​​​

 Contact Us

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

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​​​​​​​​

Home Health Agency

Report of Change Application Checklist for Change of Geographical Service Area

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.​

Checklist and Instructions - Please submit your documents in this order

Required Documents for a Change of Geographical Service Area 

Forms and Supporting Documents​

Additional Instructions

(Each for​m listed also has instructions on the form)

Cover Letter

Cover Letter

Letter on company letterhead with the following information:

  • License number
  • Facility name and 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, 1.5MB)
Licensure & Certification Application
(REVISED 7/2023) [Title 22 California Code of Regulations (CCR) section 74661 and 74667 Health and Safety Code (HSC) section 1728]

Tips:

  • Page 3, section A, item 9 – If the facility, agency, or clinic indicates they operate 24/7/365, complete “b" to indicate the hours of operations for the public. This information is used for surveying purposes.
  • Page 3, section B, item 2 –Provide the EIN of the licensee. Do not enter a Social Security number in this field.
  • Page 6, section B, item 6 — An organization must own 100 percent of the licensee to be considered a parent company. This parent company will have its own Employer Identification Number (EIN)
CMS 855A Page 23 (PDF) 
Geographic Areas of HHA 
[CCR sections 74607, 74663, and 74664]

  • ​The service area of a parent HHA may not extend beyond four hours surface travel time from the agency unless the agency serves a rural, scarcely populated area
  • Submit a list of the geographical areas (including cities, counties, and zip codes) to be served
  • Submit a web-based map



Required Documents for Medicare for Certification

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form) 

CMS 855A (PDF) 

Medicare General Enrollment Health Care Provider/ Supplier Application
  • This application is from the Federal Department of Health and Human Services
  • The completed application should be mailed directly to the appropriate fiscal intermediary




​​
Page Last Updated :