Outpatient Physical Therapy/Speech-Language Pathology Provider
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 - Please submit your documents in this order
Required Documents for a Change of Mailing Address
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Forms and Supporting Documents
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Additional Instructions
(Each form listed also has instructions on the form)
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Cover Letter
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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)
General Contact Information (name, title, phone number, fax, email address, and alternative contact information) Emergency Contact Information (name, phone number, fax, email address, alternate email, and phone number that will receive text messages) All Facility Letter Contact Information (name, phone number, fax, and email address) Facility Contact (Public Use) Information (phone number, fax, email address, and website address) Privacy Officer Contact Information (name, title, mailing address, phone number, and email address) Signature
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HS
200 (PDF, 1.5MB)
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Licensure & Certification Application
[Title 42 Code of Federal Regulations (CFR) section 485.709]
Tip:
Attachment F-1 — If the current or proposed facility, agency, or clinic is applying for Medi-Cal certification, complete Attachment F-1: Subcontractor Information and Significant Business Transactions
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