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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health



Medi-Cal Certification

Hospice - Certified part of a licensed HHA

 


To become a Medi-Cal “certified” Hospice, the Hospice needs to be a Medi-Cal certified part under a “licensed” HHA (Hospice has to be a “Service” under a licensed HHA).

If this is the case, complete the forms below.

Note: If this is a separately “licensed” Hospice that wants to be certified for Medi-Cal and/or Medicare, use the Hospice application letter and checklist located on the L&C website. Do not use this checklist

Form #​Item #Description​
Technical CHOW
Check-List​
HS 200​

​Licensing & Certification Application

  • If applying for both Medi-Cal & Medicare certification, only need one copy of this form.
​HS 328

​Notice – Effective Date of Provider Agreement

  • If applying for both Medi-Cal & Medicare certification, only need one copy of this form.
​DHCS ​9098 ​ ​ ​​Medi-Cal Provider Agreement
  • ​Must enter N/A or “same” if not applicable
  • ​The “mailing” address must match the mailing address on Item C.4., of the HS 200 form, page 3, Item 4.
  • ​Signature page must be “notarized”.
  • ​Submit the “Acknowledgement” page from the Notary Public, if applicable.
​CMS ​417 ​​Hospice Request for Certification in the Medicare Program
  • ​If this hospice is being certified for Medi-Cal “only”, this form is being requested is for the listing of the types of services.
  • ​If applying for both Medi-Cal & Medicare certification, only need one copy of this form.

 



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