HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Intermediate Care Facility/Developmentally Disabled
Intermediate Care Facility/Developmentally Disabled-Habilitative
Intermediate Care Facility/Developmentally Disabled-Nursing
Intermediate Care Facility/Developmentally Disabled-Continuous Nursing

Report of Change Application Checklist for Change of Certification

The following is a list of forms and supporting documents required for a complete application packet. Failure to include every form or document will delay processing or lead to denial.

Checklist and Instructions - Please submit your documents in this order and save a copy of all submitted documents for your records.

Required Documents for a Medi-Cal Certification

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 address Facility ID number (if known) Brief description of request to add Medi-Cal [Title 19] Applicant Contact Information (name, title, phone number, applicant contact email address) The Department will use the applicant contact email address to send all application correspondence General Contact Information (name, title, phone number, fax, email address, and alternative contact information) The Department will use this information to contact the facility for day-to-day business Emergency Contact Information (name, phone number, fax, email address, alternate email, 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) All Facility Letter Contact Information (name, phone number, fax, and email address) The Department will use this information to send All Facility Letters Facility Contact (Public Use) Information (phone number, fax, email address, and website address) The Department will use this information to store facility contact information for the public Privacy Officer Contact Information (name, title, mailing address, phone number, and email address) The Department will use this information to correspond with the facility's Privacy/Compliance Officer regarding medical breach incidents Signature
HS 200 (PDF, 1.5MB)	Licensure and Certification Application Note: If applying for Med-Cal, applicant must complete the “Subcontractor Information and Significant Business Transactions” attachment Tip: Page 6, section B, item 6 — An organization will have its own Federal tax ID number Signature must be from the applicant (Licensee/owner), not the Administrator, unless the owner is the Administrator.
CMS 3070G (PDF)	Intermediate Care Facilities for Individuals with Intellectual Disabilities Survey Report This is a “survey” report. The applicant only needs to complete the top portion of the form - the remainder will be completed during the survey.
HS 328 (PDF)	Notice - Effective Date of Provider Agreement If applying for both Medi-Cal & Medicare certification, only submit one copy of this form
DHCS 9098 (PDF, 2.9MB)	Medi-Cal Provider Agreement 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, section C, Page 3, item 4 Notarized signature page is required Submit the “Acknowledgement” page from the Notary Public

Note: Save a copy of all submitted documents for your records.

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