HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Home Health Agency

Report of Change Application Checklist for Change of Location

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 Location

Forms and Supporting 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 Applicant Contact Information (name, title, phone number, invoice contact email address, applicant contact email address) The Department will use the invoice contact email address to invoice the application fee The Department will use the applicant contact email address to send all application correspondence General Contact Information (name, title, phone number, fax, email address, and alternative contact information) The Department will use this information to contact the facility for day-to-day business Emergency Contact Information (name, phone number, fax, email address, alternate email, 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) All Facility Letter Contact Information (name, phone number, fax, and email address) The Department will use this information to send All Facility Letters Facility Contact (Public Use) Information (phone number, fax, email address, and website address) The Department will use this information to store facility contact information for the public Privacy Officer Contact Information (name, title, mailing address, phone number, and email address) The Department will use this information to correspond with the facility's Privacy/Compliance Officer regarding medical breach incidents Signature
HS 200 (PDF, 1.5MB)	Licensure & Certification Application (REVISED 7/2023) [Title 22 California Code of Regulation (CCR) section 74661] [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)
Supporting Documents	Section D - Property Information Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee If the licensee owns the property, submit a signed copy of the Grant Deed, or Bill of Sale If the licensee rent, lease, or sublease, submit the signed copy of the agreement (i.e., rental agreement and/or master lease between the property owner/manager and the perspective licensee)
CMS 1572 (a) & (b) (PDF)	Home Health Agency Survey and Deficiency Report The CMS 1572 form is required Complete pages (a) and (b), items 1-20, as indicated on the form Note: If licensed “only”, the CMS 1572 form is required to document the services requested and to assist the local district office with the survey process. If requesting certification, the CMS 1572 form is required to apply for Medicare certification
CMS 855A Page 23 (PDF, 1MB)	Geographical Areas of HHA [Title 22 CCR sections 74607, 74663, and 74664] The service area of a parent HHA may not extend beyond four (4) 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 & zip codes) to be served Submit a web-based map

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, 1MB)

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

HHS 690 (PDF)

Assurance of Compliance

OCR’s online portal is: Office for Civil Rights (https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf)
Once the on-line submission is completed, an electronic notification from OCR stating the “Assurance of Compliance form was submitted successfully”-will be received by the applicant
Submit a copy of this notification