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

Medi-Cal Certification

Home Health Agency Branch Office


If you answered “YES” on Item A.7. of the HS 200 form (Do You Wish to Apply for the Medi-Cal Program?) and your HHA wants to provide services to Medi-Cal beneficiaries (under Title 19) submit the forms below, as indicated.

Note: The agency is required to be licensed prior to seeking certification status.

Form #Item #​Description
Branch Office​
CMS 1572 (a)&(b)​

​Home Health Agency Survey and Deficiency Report

Note: If applying for both Medi-Cal and Medicare certification, only one copy of this form is required.

  • If this HHA is being certified for Medi-Cal “only”, the only reason this form is being requested is for the listing of the types of services.
  • Complete pages (a) and (b), items 1-20, as indicated on the form.
  • If this HHA is adding hospice as a “service”, identify the hospice service on page 2, Item 18, number 13 (under “Other”), of the CMS 1572 form by writing in the word hospice.


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