health care facility licensing and certification

Hospice Agency

Report of Change Application Checklist for Change of Certification

The following is a list of application forms and supporting documents required for a complete application packet. Failure to include each of the forms and documents will delay processing.

Medi-Cal
Medicare

Checklist and Instructions - Please submit your documents in this order

Required Documents for a Change of Certification

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
Cover Letter	Cover Letter Letter on company letterhead with the following information: License number (only applicable for CHOW) Facility name and ID number (if known) Brief description of request Applicant Contact Information (name, title, phone number, invoice contact email address, applicant contact email address) The Department will use the invoice contact email address to invoice the application fee The Department will use the applicant contact email address to send all application correspondence General Contact Information (name, title, phone number, fax, email address, and alternative contact information) The Department will use this information to contact the facility for day-to-day business Emergency Contact Information (name, phone number, fax, email address, alternate email, and phone number that will receive text messages) The Department will use this information to contact the provider in the event of an emergency using the California Health Alert Network (CAHAN). All information provided must allow CAHAN to contact the provider on a 24/7/365 basis for distribution of health alerts. For additional information: CAHAN (https://calhospital.org/calhospitalprepare/) All Facility Letter Contact Information (name, phone number, fax, and email address) The Department will use this information to send All Facility Letters Facility Contact (Public Use) Information (phone number, fax, email address, and website address) The Department will use this information to store facility contact information for the public Privacy Officer Contact Information (name, title, mailing address, phone number, and email address) The Department will use this information to correspond with the facility's Privacy/Compliance Officer regarding medical breach incidents Signature
HS 200 (PDF, 1.5MB)	Licensure & Certiﬁcation Application (Revised 7/2023) [Health and Safety Code (HSC) 1749; Title 22 CCR § 74812 (c)]
Form and Supporting Documents	Section A – Application Information [22 CCR 74812 § (c)(6) – (c)(7)] Page 3, item 9 - If the facility, agency, or clinic indicates they operate 24/7/365, complete "b" to identify business days and hours of operation of the hospice agency’s commercial office. Page 3, item 10 - If the hospice agency is under construction, the application must include the following: A certiﬁcate of occupancy A copy of the construction approval form issued by the Department of Health Care Access and Information (HCAI) The actual or estimated dates of construction commencement and completion
Form and Supporting Documents	Section B – Licensee Information [22 CCR 74812 § (c)(9) – (c)(13), (c)(20)] The taxpayer identiﬁcation number or federal employer identiﬁcation number or both published by the Internal Revenue Service under the legal name of the applicant, or the social security number issued under the legal name of the applicant. (Submit one of the following) Form 941- Employer’s Quarterly Federal Tax Return Form 8822 or 8822-B Change of Address Letter 147-C EIN Confirmation Notiﬁcation Form SS-4 Confirmation Notiﬁcation Filing statements endorsed by the California Secretary of State containing the date when the business was created, the business entity type, and the business entity number, if the applicant is applying as a business entity. A copy of the proposed or existing organizational chart displaying the names of the individuals or entities having authority or responsibility for the operation of the agency. If there is a parent organization the application must also include, but is not limited to: The parent organization’s name, taxpayer identiﬁcation number or federal employer identiﬁcation number, and address. A copy of the proposed or existing organizational chart displaying the names of the individuals or entities having authority or responsibility for the operation of the parent organization. A list of all health facilities, clinics, and home health agencies the parent organization is operating, along with identifying any other agencies, facilities, clinics, or multiple locations that the applicant has been licensed for, operated, managed, held a ﬁve percent or more ownership interest or control interest, orservices as a director or officer of, and the basis upon which the applicant exercises control and possession. This must include locations both within and outside the State of California.
Form and Supporting Documents	Section C – Facility, Agency, or Clinic Information [22 CCR 74812 § (c)(31)] A copy of the ﬁctitious name statement if the applicant will be operating under a different name other than the applicant’s legal name
Form and Supporting Documents	Section D - Property Information [22 CCR 74812 § (c)(17) – (c)(19)] Submit the supporting documentation when the change includes a Change of Location or Property Owner. The property ownership information, including, but not limited to: The type of control of the property, including own, rent, lease, or sublease Evidence of control of the property, including, but not limited to, a copy of the grant deed, a bill of sale, a lease, or sublease agreement Name and address of the property owner or manager A ﬂoor plan, issued by the property owner, that coincides with the space If the property is leased, the tenant’s name and physical address of the hospice If the property is subleased, the subtenant’s name, physical address of the hospice, a copy of the master lease, and a letter that states the owner is aware of the sublet and the occupancy of the subtenant The hospice agency must be located in a commercial building either owned by the licensee or leased/sub-leased exclusively by the licensee for a minimum of 12 months Proof the applicant has obtained general liability insurance coverage for the hospice which covers the premises and operation. General liability insurance coverage limits must not be for an amount less than $100,000 per claim nor a minimum annual aggregate of not less than $300,000 Proof the applicant has obtained and maintains worker’s compensation coverage for the hospice that covers the premises and operation. Worker’s compensation coverage limits must not be for an amount less than $100,000 per claim nor a minimum annual aggregate of not less than $300,000.
Form and Supporting Documents	Section F – Subcontractor Information and Signiﬁcant Business Transactions [22 CCR § 74812(c)(34)] If the current or proposed facility, agency, or clinic, is applying for Medi-Cal certiﬁcation, complete attachment F-1: Subcontractor Information and Signiﬁcant Business Transaction (Previously referred to as DHCS 6207 – Medi-Cal Disclosure Statement)
Form and Supporting Documents	Section G – I (We) Accept Responsibility to [22 CCR 74812 § (c)(8)] One form of current and valid photo identiﬁcation which veriﬁes that the individual completing the application is age 18 years or older. Proof of identity includes, but is not limited to, a driver’s license or state identiﬁcation card issued by the Department of Motor Vehicles, United States or foreign passport or passport card, or United States military card or military dependent’s ID card

Medi-Cal Certification Documents

Forms and Supporting Documents

Additional Instructions
(Each form listed also has instructions on the form)

DHCS 9098 (PDF)

Form and Supporting Documents

Medi-Cal Provider Agreement

[22 CCR § 74812(c)(34)]

Do not leave any questions blank. Enter “same” or “N/A” if not applicable
The mailing address must be the same as reported on the HS 200 form
Notarized signature page is required
Submit the “Acknowledgement” page from the notary public, if applicable

HS 328 (PDF)

Form and Supporting Documents

Notice - Effective Date of Provider Agreement

[22 CCR § 74812(c)(34)]

If applying for both Medi-Cal and Medicare certiﬁcation, only submit one copy of this form

Medicare Certification Documents

Forms and Supporting Documents

Additional Instructions
(Each form listed also has instructions on the form)

CMS 417 (PDF)

Form and Supporting Documents

Hospice Request for Certiﬁcation in the Medicare Program

[HSC § 1749(d); 22 CCR § 74812 (c)(21), (c)(33)(b]

The form requires an original signature and date
If this freestanding hospice is “licensed only,” complete this form to identify the types of services

CMS 643 (PDF)

Form and Supporting Documents

Hospice Survey and Deﬁciencies Report

[22 CCR § 74812(c)(33)]

Fill out the Name of Facility only
Submit both pages

CMS 1561 (PDF)

Form and Supporting Documents

Health Insurance Beneﬁts Agreement

[22 CCR § 74812(c)(33)]

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”

Online Portal

Form and Supporting Documents

Assurance of Compliance

[22 CCR § 74812(c)(33)]

Navigate to the Office of Civil Rights (OCR) online portal (https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf)
Once the online submission is completed, an electronic notiﬁcation from OCR stating the Assurance of Compliance form was submitted successfully will be received by the applicant
Submit a copy of this notiﬁcation

CMS 855A (PDF)

Medicare General Enrollment Health Care Provider/Supplier Application For awareness:

[22 CCR § 74812(c)(33)]

This application is from the Federal Department of Health and Human Services
The completed application should be mailed directly to the appropriate ﬁscal intermediary