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Licensing and Certification Program

Applications for a Hospice

In addition to the forms below, you are required to submit additional documents for a Change of Ownership and the Geographic Location of the BRANCH Office.  These documents must be submitted with your completed application.  The required information and instructions are listed on the appropriate checklist contained in one of the following letters:

Hospice Provider Application Request Letter and Instructional Checklist (PDF)

Hospice Facility Application Request Letter and Instructional Checklist (PDF)

Hospice

Required Forms to be Licensed:

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

Required Forms to be Certified with Medicare:

Hospice – ADDING ALTERNATE SITE TO HOSPICE LICENSE

Required Forms for an Alternate Site to be Licensed:

Contact Us:

Phone: (916) 552-8632

Email: CAU@cdph.ca.gov

Staff will respond to your inquiry within 48 hours.

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