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Licensing and Certification Program

Applications for a Home Health Agency

In addition to the forms below, you are required to submit additional documents for a Change of Ownership; the Geographic Location of the BRANCH Office; and the Capitalization information for Medi-Cal certification “only”.  These documents must be submitted with your completed application.  The required information and instructions are listed on the checklist contained in the Home Health Agency Application Request Letter and Instructional Checklist (PDF) letter.

Home Health Agency (HHA)

Required Forms to be Licensed:

Required Forms to be Certified with Medicaid/Medi-Cal:

Required Forms to be Certified with Medicare:

Home Health Agency – BRANCH OFFICE

Required Forms for a Branch Office to be Licensed:

HOSPICE -- to Become a Certified Part of a HHA License

Required Forms for a HOSPICE to be Certified with Medicaid/Medi-Cal:

Required Forms for a HOSPICE to be Certified with Medicare:

Contact Us:

Phone: (916) 552-8632

Email: CAU@cdph.ca.gov

Staff will respond to your inquiry within 48 hours.

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