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EDMUND G. BROWN JR.
Governor

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



Hospice Provider: 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
​HS 328​Notice – Effective Date of Provider Agreement
  • If applying for both Medi-Cal & Medicare certification, only need one copy of this form.
CMS 417Hospice Request for Certification in the Medicare Program
(H&S Code Section 1749.5)
  • If applying for both Medi-Cal and Medicare certification, only need one copy of this form.
  • Complete this form as indicated.
​​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
  • This application is from the Federal Department of Health and Human Services.
  • This application is required for "initial" and "CHOW" applications.
  • The completed application should be mailed directly to the appropriate fiscal intermediary.
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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