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Phone: (916) 552-8632

For application status requests, please include the following in your email:

  • Application ID (if applicable)
  • Name of Facility or Agency
  • License or Facility/Agency # (if applicable)
  • Address
  • Facility or Provider Type
  • Date Documentation Sent
  • Contact Number​​​​​​​​​​​​​​​

Hosp​ice Agency 

Report of​ Change Application Checklist for Change of Location

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.

Checklist and I​nstructions - Please submit your documents in this or​der

Required Documents to Relocate a Facility 

Forms and​​​ Supporting Docume​​nts​

Additional Instructions

(Each for​m listed also ​has instructions on the form)

Cover Letter

Cove​r Lett​er

Letter on company letterhead with the following information:

  • License number
  • Facility name and ID number (if known)
  • Brief description of request
  • Previous and proposed/new location
  • Contact information (name, title, phone number, and e- mail address)
  • Emergency Contact Information (name, email, alternate email, phone, fax, 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 (
  • Contact Information for the Privacy Officer or Designee responsible for submitting and responding to medical breach incidents (name, title/position, mailing address, phone number, and email address) 
  • Signature
HS 200 (PDF, 1.5MB) 

Licensure ​& Certification Application

(REVISED 7/2023) [Health and Safety Code (HSC) section\1339.41(d)(5)]


  • Page 3, section A, item 9 – If the facility, agency, or clinic indicates they operate 24/7/365, complete “b" to indicate the hours of operations for the public. This information is used for surveying purposes.
  • Page 3, section B, item 2 –Provide the EIN of the licensee. Do not enter a Social Security number in this field.
  • Page 6, section B, item 6 An organization must own 100 percent of the licensee to be considered a parent company. This parent company will have its own Employer Identification Number (EIN)​​
​Supporting Documents 
Section A.10 - Health Care Access & Information (HCAI) and/or Certificate of Occupancy (CO) 

If the facility is newly constructed or a remodeled building, or if this is not a previously licensed facility the facility shall be under the jurisdiction of HCAI or the local building department

  • Hospice Facility located within the physical plant of another facility [HSC 1339.43(e)(1)]
    • Shall be under the jurisdiction of HCAI
    • Submit HCAI CO, Construction Final (CF) or Substantial Completion (SC)
  • Freestanding Hospice Facility located on the site of or is physically connected to a health facility that is under the jurisdiction of both [HSC 1339.43(f)]
    • Submit new construction or renovation plans to HCAI for review and approval
    • Submit OSHPD CO, CF or SC
  • All other freestanding Hospice Facility [HSC 1339.43(d)(1) and (2)]
    • Shall be under the jurisdiction of the local building department
    • Submit CO from local building department building department
​Supporting Documents 

Section D - Property Information

Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee

  • If the licensee owns the property, submit a signed copy of the Grand Deed, or Bill of Sale  
  • If the licensee rent, lease, or sublease, submit the signed copy of the agreement (i.e., rental agreement and/or master lease between the property owner/manager and the perspective licensee) 
​CMS 855A (Page 23 Only) (PDF) 
Geographical Service Area 

  • Submit a list of the geographical areas (including cities, counties, and zip codes) to be served
  • Submit a web-based map
  • Hospice agencies must obtain prior approval of an expansion of their geographic service area from the Centers for Medicare and Medicaid Services (CMS) and the California Department of Public Health, Licensing & Certification Program

Medi-Cal Certification D​ocuments

Forms and Supporting Documents
Additional Instructions
(Each form listed a​lso has instructions on the form)

DHCS 9098 (PDF)

Medi-Cal Provider Agre​ement

  • 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

Medicare Certification Documents

Forms and Supporting Documents​
Additional Instruc​​tions
(Each form listed also has instructions on the form)

​​CMS 417​ (PDF) 
Hospice Requ​est for Certification in the Medicare Program 
  • 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 855A (PDF) 

Medicare General Enrollment Health Care Provider/Supplier Application

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

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