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EDMUND G. BROWN JR.
Governor

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



Medicare Certification​

​Form #Item #​Description
Medicare Certification​
Check-List​
​HS 328​Notice – Effective Date of Provider Agreement
  • 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 form is available from the Federal “Department of Health and Human Services”. The completed form should be mailed directly to the appropriate Fiscal Intermediary.
  • ​​Part of the instructions on the CMS 855A application require that all HHAs 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 Medicare program.
    [Title 42 CFR, Section 489.28]

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 CFR, 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”).
​​8. Provide the type of ownership (free standing or provider based).
​9. Provide the geographic location of the HHA and urban/rural status.
​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.”
​CMS 1572
(a)&(b) ​ ​
​Home Health Agency Survey and Deficiency Report
  • ​Complete pages (a) and (b), items 1-20, as indicated on the form. The remaining pages will be completed during the survey.
  • ​If applying for both Medi-Cal and Medicare certification, only need one copy of this form.
​OMB
No. 0990-
0243 ​ ​

​Civil Rights Information Request for Medicare Certification

Note: These items will be reviewed and approved by OCR.

  • ​Complete and “sign” form (original signature).
  • ​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. This HHS 690 form is the first document required to be submitted on the above OMB No. 0990-0243 form.


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