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

Medi-Cal Certification ​

Home Health Agency


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
Medi-Cal Certification​
​HS 328

​Notice – Effective Date of Provider Agreement

  • If applying for both Medi-Cal & Medicare certification, only need one copy of this form.
​DHCS 6207

Medi-Cal Disclosure Statement​

NOTE: Only complete section V.

​DHCS 9098

​Medi-Cal Provider Agreement

  • Do not leave any questions blank. Enter N/A or “same” if not applicable.
  • The “mailing address” must be the same as reported on the HS 200 form on page 3, Item 4.
  • Signature page must be notarized.
  • Submit the “Acknowledgement” page from the Notary Public, if applicable.
  • If applying for both Medi-Cal & Medicare certification, only need one copy of this form.
​CMS 1572

​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.
​Capital ​ ​ ​ ​ ​ ​ ​ ​ ​

​Capitalization Requirements for Medi-Cal “only” certification of a HHA

  • If the HHA applicant wants Medi-Cal and Medicare, refer to the instructions contained on the CMS 855A application (Medicare General Enrollment Health Care Provider/Supplier Application). This form is listed under the Medicare forms on the following pages.

Capitalization – Financial Resources for Medi-Cal “only”: (Title 42 CFR, Section 489.28)

  • These capitalization requirements are only for a licensed HHA to be certified with Medi-Cal
  • The Provider Certification Section must approve the capitalization plan prior to conducting a Medi-Cal certification survey. HHAs that are Medi-Cal “only” must submit evidence that the licensee has sufficient initial reserve operating funds (Capitalization) to operate for the first three (3) months (90 days) in the Medi-Cal program.
​This capitalization evidence should consist of the following

1. Business plan/structure.

2. ​Projected expenses for the first three (3) months (90 days) of operation broken down by rent, utilities, salaries, overhead, etc.

​3. A copy of an “official” bank statement, certificate of deposit, etc. (in the name of the licensee) providing current balances. Must show that the applicant has available funds to operate HHA first 3 months and that at least 50% of these funds are non-borrowed funds.
[Title 42 , Section 489.28(d)]
​4. An attestation (signed and dated) from an Officer of the bank that the funds are in the account(s) and that the funds are immediately available.
​5. An attestation (signed and dated) from the licensee stating that the required funds are available immediately.
​6. Projected number of visits for the first three (3) months of operation.
​7. Projected number of visits for the first year of operation following certification (this N/A if licensed “only”).



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