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HEALTH CARE FACILITY LICENSING AND CERTIFICATIONā€‹ā€‹

 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 Numberā€‹
ā€‹

Intermediate Care Facility/Developmentally Disabled
Intermediate Care Facility/Developmentally Disabled-Habilitative
Intermediate Care Facility/Developmentally Disabled-Nursingā€‹
Intermediate Care Facility/Developmentally Disabledā€‹-Continuous Nursingā€‹

Report of Change Application Checklist for Change of Certification

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.

  • ā€‹Medi-Calā€‹ā€‹

Checklistā€‹ and Instructions - Pā€‹lease submit your documents in this order

Required Documents for a Medi-Cal Certification

ā€‹Forms and Supportingā€‹ Documentsā€‹ā€‹ā€‹ā€‹ā€‹ā€‹

ā€‹ā€‹Additional Instructions

(ā€‹ā€‹ā€‹Each form ā€‹listed also has instructions on the form)ā€‹

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] 
  • 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: CAHANā€‹ā€‹ (https://www.calhospitalprepare.org/post/california-health-alert-network-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) ā€‹
  • Signature
HS 200 (PDF, 1.5MB)


Licensure and Certification Application

Note:
  • If applying for Med-Cal, applicant must complete the ā€œSubcontractor Information and Significant Business Transactionsā€ attachment 
Tip:
  • Page 6, section B, item 6 ā€” An organization will have its own Federal tax ID number
CMS 3070Gā€‹ā€‹ (PDF)

Intermediate Care Facilities for Individuals with Intellectual Disabilities Survey Report ā€‹ā€‹

This is a ā€œsurveyā€ report. The applicant only needs to complete the top portion of the form - the remainder will be completed during the survey. 

ā€‹HS 328ā€‹ ā€‹(PDF)ā€‹


Notice - Effective Date of Provider Agreement

ā€‹If applying for both Medi-Cal & Medicare certification, only submit one copy of this formā€‹ā€‹ā€‹ā€‹ā€‹

ā€‹DHCS 9098ā€‹ (PDF)ā€‹ 

ā€‹Medi-Cal Provider Agreement

  • Do not leave any questions blank. Enter ā€œsameā€ or ā€œN/Aā€ if not applicable ā€‹
  • 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  ā€‹
  • Submit the ā€œAcknowledgementā€ page from the Notary Public ā€‹
    ā€‹
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