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HEALTH CARE FACILITY LICENSING AND CERTIFICATION​

Intermediate Care Facility/Developmentally Disabled ​​​
&
Intermediate Care Facility/Developmentally Disabled-Habilitative​​

Report of Change Application Checklist for Change of National Provider Identifier

The following is a list of application 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 - P​lease submit your documents in this order and save a copy of all submitted documents for your records. 

Required Documents for a Change of National Provider Identifier

​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

  • 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 t​his 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 20​0 (PDF, 1.5MB)

Licensure & Certification Application 

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.

​

Medi-Cal Certification Documents

Forms and Supporting Documents​​​

Additional Instructions

(Each form listed also has instructions on the form) ​

​DHCS 90​98 (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

  • 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

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