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EDMUND G. BROWN JR.
Governor

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



​Medicare Certification

Home Health Agency Branch Office

 

 

Form #Item #​Description
Branch Office​
Check-List​
​CMS ​1561 ​ ​​Health Insurance Benefit Agreement
  • ​Submit two (2) signed copies with “original” signatures.
  • ​Initial Application: Sign the top signature block entitled “Accepted for the Provider of Services By.”
  • ​CHOW: Sign the bottom signature block entitled “Accepted For The Successor Provider of Services By.”

 



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