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State of California—Health and Human Services Agency
California Department of Public Health

Hospice Facility: Medi-Cal Certification
Applicant Checklist

A "certified" HOSPICE has to be separately licensed as a hospice. The following forms and information are required for Medi-Cal certification.

If you answered "YES" on Item A.7.of the HS 200 form (Do You Wish to Apply for the Medi-Cal Program?) and your hospice wants to provide services to Medi-Cal beneficiaries (under Title 19), submit the following forms with your "initial" application package.

Once the hospice has become certified for Medicare, they may provide services to Medi-Cal beneficiaries, if requested. The hospice is required to be licensed prior to seeking certification status.

Note: All forms listed are in PDF format. 

Form #​Description​Check List
HS 328

​Notice – Effective Date of Provider Agreement

  • If applying for both Medi-Cal & Medicare certification, only need one copy of this form.
DHCS 6207

​Medi-Cal Disclosure Agreement

  • Only complete section V.
DHCS 9098

​Medi-Cal Provider Agreement

  • Do not leave any questions blank. Enter N/A or "same" if not applicable.
  •  The "mailing address" must be the same as reported on the HS 200 form.
  • Signature page must be "notarized."
  • Submit the "Acknowledgement" page from the Notary Public, if applicable.
CMS 417

​Hospice Request for Certification in the Medicare Program

  • If applying for both Medi-Cal and Medicare certification, only need one copy of this form.
  • If this hospice is being certified for Medi-Cal "only," the only reason this form is being requested is for the listing of the types of services.
  • Complete this form as indicated.

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