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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-Nursing
ICF/DD-Continuous Nursing​​

Report of Change Application Checklist for Change of Mailing Address

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 Mailing Address

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
  • 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 He​alth 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 (​an)
  • 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 

Note: Only DHCS 9098 and cover letter are required if the request is for a change of Pay-to addres​s

HS 200 (PDF)

Licensure & Certification Application​


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

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

Note: Only required for change of Mailing Address applications for Facility

  • 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

Note: Only DHCS 9098 and Cover Letter are required if the reques​t is for a change of Pay-to address

Medicare Certification Documents 

​Forms and Supporting Documents
​Additional Instructions
(Each form listed also has instructions ​on the form)

CMS 855A ​(PDF)

Medicare Gene​ral 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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