HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Contact Us

Phone: (916) 552-8632
Email: CAB@cdph.ca.gov

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

Hospice Agency

Report of Change Application Checklist for Change of Service

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

Checklist and Instructions - Please submit your documents in this order

Required Documents to Add/Remove a Service

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

Cover Letter

Letter on company letterhead with the following information:

License number
Facility name and ID number (if known)
Brief description of request
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) (https://www.calhospitalprepare.org/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)

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 own
100 percent of the licensee to be considered a parent company. This parent company will have its own Employer Identification Number (EIN)

Medicare Certification Documents

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

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