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EDMUND G. BROWN JR.
Governor

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



Hospice Provider: Additional Site - Medicare Certification
Applicant Checklist

​A "certified" HOSPICE has to be separately licensed as a hospice. The following forms and information are required for Medicare certification.
Note: All forms listed are in PDF format.

Form #​DescriptionCheck List
​​CMS 643​Hospice Survey and Deficiencies Report
  • Complete the top of the 1st page. The remainder will be completed during the survey.
CMS 855A

​Medicare General Enrollment Health Care Provider/Supplier Application

Additional Hospice Sites:

  • This application is from the Federal Department of Health and Human Services.
  • The completed application should be mailed directly to the appropriate fiscal intermediary.
  • The addition of an additional hospice sites must have prior approval from Centers for Medicare and Medicaid Services (CMS) for certification of a hospice.
  • CMS will determine if the Conditions of Participation continue to be met with the addition of the new additional hospice site.
CMS 1561​Health Insurance Benefit Agreement

Submit two (2) signed copies with "original" signatures:

  • Initial Application: Sign the top signature block entitled "Accepted for the Provider of Services By."
  • CHOW: Sign the bottom signature block entitled "Accepted for the Successor Provider of Services By."
​OMB No. 0990-0243​Civil Rights Information Request for Medicare Certification
  • Complete and "sign" form (original signature).
  • Submit all of the documents required on Part 11 of this OMB form. All of these documents need to be "identified" by the corresponding number on the OMB form. The first document required is the HHS 690 form below.
  • These items will be reviewed and approved by OCR.
​​HHS 690​Assurance of Compliance [42 CFR, Section 489.10(b)]
  • Submit 1 copy. This HHS 690 form is the first document required to be submitted on the above OMB No. 0990-0243 form.


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