Forms and Supporting Documeāāntsā
| Additional Instructions
(Each forām listed also has instructions on the form)
|
Cover Letter
| Coveār Letter Letter on company letterhead with the following information: - License number
- Facility name and ID number (if known)
- Brief description of request
- Previous and proposed/new location
- 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: 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)
- Signatureā
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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 ā If the facility, agency, or clinic indicates they operate 24/7/365, complete āb" to indicate the hours of operations for the public. This information is used for surveying purposes.
- Page 3, section B, item 2 āProvide the EIN of the licensee. Do not enter a Social Security number in this field.
- Page 6, section B, item 6 ā 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)
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āSupporting 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)
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āCMS 1572 (a) & (b) (PDF)
| āHome 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 āonly", 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
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āCMS 855A Page 23 (PDF)
| āGeographical 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
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