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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 Mailing Address

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 Mailing Address

Forms and Suppo​rting​ Documents

Additional Instructions

(Each form 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. Indicate if the change of Mailing Address is for the Licensee or for the facility
  • Contact information (name, title, phone number, and email 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: (CAH​AN) (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 Regulation (CCR) section 74661 (a) (1), (Health and Safety Code (HSC) 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 Indentification Number (EIN)

Medi-Cal Certification Documents 

Forms and Supporting Documents
Additional Instructions
(Each form listed also has instructions on the form)

DHCS 9098 (PDF)​
Medi-Cal Provider Agreement
  • Do not leave any questions blank. Enter “same” or “N/A” if not applicable
  • The mailing address must be the same as reported on the HS 200 form
  • Notarized signature page is required
  • Submit the “Acknowledgement” page from the notary public, if applicable

Medicare Certification Documents 

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​​

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