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:

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

Hospice Agency and Hospice Facility

Report of Change Application Checklist for Change of Name

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 Instructions - Please submit your documents in this order

Required Documents to Change the name of the Facility or Licensee

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. Include previous and proposed/new name 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 24/7/365 basis for distribution of health alerts. For additional information: CAHAN (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, 1.5MB)	Licensure & Certification Application (Revised 7/2023) [Health and Safety Code (HSC) 1748(b) (HSC) section 1339.41(d)(3)] 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)
Supporting Documents	Board Resolution Submit Board Resolution Letter
Supporting Documents	Restated Articles of Incorporation (only required for a licensee or parent company name change) Submit Restated Articles of Incorporation

Medi-Cal Certification Documents

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

DHCS 9098 (PDF)

Medi-Cal Provider Agreement (only required for changes to the business or legal name)

Do not leave any questions blank. Enter “same” or “N/A” if not applicable
The mailing address must be the same as reported on 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 Instructions

(Each form listed also has instructions on the form)

CMS 417 (PDF)

Hospice Request for Certification in the Medicare Program

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

CMS 855B (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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