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.
Add
Remove
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
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://www.calhospitalprepare.org/cahan)
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
Licensure & Certification Application
(REVISED 7/2023) [Health and Safety Code (HSC) section 1748(b)]
Tips:
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 own100 percent of the licensee to be considered a parent company. This parent company will have its own Employer Identification Number (EIN)
Forms and Supporting Documents
Additional Instructions(Each form listed also has instructions on the form)
CMS 417 (PDF)
Hospice Request for Certification in the Medicare Program
[HSC section 1749(b)(1) – (b)(7); Standards of Quality Hospice Care (SQHC, 2003, section 2.1)]
The form requires an original signature and date
If this freestanding hospice is "licensed only" complete this form to identify the types of services