Cover Letter

Letter on company letterhead with the following information:

• License number (only applicable for CHOW)
• 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​

Licensure & Certification Application (Revised 07/2023)

[Health and Safety Code (HSC) section 1748(b)].

Tip:

• 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. 
• Page6, 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)
  

​B.3 - Organizational Chart 

Submit an organizational chart if the type of entity, identified on the HS 200 is a for profit corporation, general partnership, limited liability company (LLC), limited liability partnership, limited partnership, or non-profit .The organizational chart needs to display the following:

• Applicant’s owners, including ownership percentages, Tax IDs/EINs and all directors, board members, corporate officers, LLC members/managers, and/or partners 
• If the licensee is a subsidiary of another organization Licensee identified in Section B.1, submit an organizational chart to display the relationship

• Parent company of applicant, if applicable, and all of the licensed agencies/facilities it is operating - see B.6

Note: Submit the HS 215A form for each of these individuals

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 Grant 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)
  

​​​Section F.1 - Subcontractor Information and Significant Business Transactions

If the current or proposed agency is applying for Medi-Cal certification, complete and submit the Attachment F-1: Subcontractor Information and Significant Business Transactions.​

Note: The attachment F-1 document replaces the DHCS 6207 Medi-Cal Disclosure Statement entirely. 

Section H – Facility Information Sheet

Each individual must complete and submit the Facility Information Sheet for each facility and/or agency with which the individual has a current or past relationship within the last three years. This sheet must also include any facilities licensed by the California Department of Social Services. The following must be completed for each facility and/or agency:

• Facility name
• Facility address
• Type of facility
• Type of business entity (include EIN Number)
• Individual’s nature of involvement
• Individual’s dates of involvement

Administrative Organization

Along with the HS 309, the following supporting documents according to organizational type must be submitted:​

Limited Liability Company (LLC)

• Filing Statement from the Secretary of State
• Articles of Organization
• Operating Agreement
• List of Managing Members (only if additional space is needed to input all managing members)

Public Agency

Copy of signed Resolution

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 providers 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 (CDPH) Licensing & Certification Program

• 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
  

Hospice Request for Certification in the Medicare Program ​

[HSC section 1749(b)(1) – (b)(7);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

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

Assurance of Compliance​

• The Office of Civil Rights (OCR) online portal is: Office for Civil Rights (https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf)
• Once the online submission is completed, an electronic notification from OCR stating the Assurance of Compliance form was submitted successfully will be received by the applicant
• Submit a copy of this notification