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Phone: (916) 552-8632

For application status requests, please include the following in your email:

  • Application ID (if applicable)
  • Name of Facility or Agency
  • License or Facility/Agency # (if applicable)
  • Address
  • Facility or Provider Type
  • Date Documentation Sent
  • Contact Number​​

Intermediate Care Facility/Developmentally Disabled ICF/DD-Habilitative

Report of Change Application Checklist for Change of Name

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.

Checklist and Instructions - P​lease submit your documents in this order

Required Documents for a Change of Name

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
  • Indicate if the change of the name is for the Licensee and/or the Facility
  • Facility ID number (if known)
  • Brief description of request
  • Previous and ​proposed/new name
  • 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 (​ahan)
  • 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​
HS 200 (PDF)
Licensure & Certification Application 

ICF/DD: Title 22 California Code of Regulations (CCR) section 76225(d)

ICF/DD-H: 22 CCR section 76844(b)(4) and Health and Safety Code (HSC) 1265


  • Page 6, section B, item 6 — An organization will have its own Federal tax ID number
​Supporting Documents

Board Resolution

ICF/DD: [22 CCR section 76205(a)(11)]

ICF/DD-H: [HSC section 1265(i)]

Submit a copy of board resolution signed by officers and directors authorizing the facility name change and with the effective date.

​Supporting Documents

Articles of Incorporation

ICF/DD: [22 CCR section 76205(a)(2)]

ICF/DD-H: [HSC section 1265(i)]

If the Licensee name or Corporate name changes, submit a copy of amended Articles of Incorporation filed with the CA Secretary of State

Note: In case of entity conversion, submit a copy of conversion document (  filed with the CA Secretary of State

Medi-Cal Certification Documents 

​Forms and supporting documents ​
Additional Instructions

(Each form listed also has instructions on the form)

DHCS 9098​ (PDF)
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
  • Notarized signature page is required
  • Submit the “Acknowledgement” page from the Notary Public, if applicable
CMS 855A (PDF)

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
  • ​This document does not go to CAB
​ ​​
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