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EDMUND G. BROWN JR.
Governor

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



Medicare Certification

Hospice - Certified part of a licensed HHA​

 


To become a Medicare “certified” Hospice, the Hospice needs to be a Medicare 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​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.
​CMS 417

Hospice Request for Certification in the Medicare Program

  • If applying for both Medi-Cal & Medicare certification, only need one copy of this form.
​CMS 855A

Medicare General Enrollment Health Care Provider/Supplier Application

  • This application is required for “initial” and “CHOW” applications.
  • The completed application should be mailed directly to the appropriate Fiscal Intermediary.
​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.”
​OMB No. 0900 - 0243 ​ ​ ​

Civil Rights Info Request for Medicare Certification

These items will be reviewed and approved by OCR.

  • ​Complete and “sign” form (original signature).
  • ​Submit copy of all items required on the form. All 9 items need to be “identified” and accounted for. However, if less than 15 employees, Item #6 does not apply.
  • ​Submit all of the documents required on Part 11 of this OMB form. All of these documents need to be “identified” by the corresponding number on the OMB form. The first document required is the HHS 690 form below.
​HHS ​690 ​​Assurance of Compliance
  • ​Submit 1 copy. Actually, this is Item #1 of the OMB No. 0990-0243 form.
  • ​Submit 1 copy. This HHS 690 form is the first document required to be submitted on the above OMB No. 0990-0243 form.

 



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