HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Contact Us

Phone: (916) 552-8632
Email: CAB@cdph.ca.gov

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

Outpatient Physical Therapy/Speech-Language Pathology Provider

Extension Site Application Checklist

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 Adding an Extension Site

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: Proposed Parent Facility (Primary Site) Facility name and address Facility ID number (if known) Brief description of request to operate an extension site Statement that the OPT/SP extension location is located sufficiently close to share administration, supervision, and services with the primary site. 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 (https://www.calhospitalprepare.org/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) Extension Site Facility name and address 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 (https://www.calhospitalprepare.org/cahan) Signature
HS 200 (PDF, 1.5MB)	Licensure & Certification Application [Title 42 Code of Federal Regulations (42 CFR) section 485.709, 420 Subpart C, and 455 Subpart B]
Supporting Documents	A.10 – Certificate of Occupancy [42 CFR section 485.723(a)(1)] If construction occurred and if the construction resulted in a new building or addition: Submit a Certificate of Occupancy This is not applicable if there were alterations or repairs to existing buildings performed or conversion of space
Supporting Documents	B.3 – Organizational Chart – Owner Type [42 CFR section 485.709(a)] Submit an organizational chart if the owner is a for profit corporation, nonprofit corporation, limited liability company (LLC), or general partnership. The organizational chart needs to display the following: Applicant’s owners, including ownership percentages, Tax IDs/EINs and all directors, board members, corporate officers, LLC, members/managers, and/or partners Note: Submit the HS 215A form for each of these individuals Parent company of applicant, if applicable, and all of the licensed agencies/facilities it is operating- see B.6
Supporting Documents	B.3 – Non-Profit Status – Owner Type Submit a copy of the IRS Tax Exempt Determination Letter showing the non-profit 501(c)(3) status (if applicable)
Supporting Documents	B.4.b – License Revocation (if applicable) Submit additional information, including all ownership and facility information, date and any final action
Supporting Documents	B.6 – Organizational Chart [42 CFR section 485.709(a)] If licensee is a subsidiary of another organization, an organizational chart must be submitted
HS 215A (PDF)	Applicant Individual Information [42 CFR sections 420.206(a)(3), 455.104, 485.709(a)] This form must be completed and signed for the following individuals: Administrator of the facility Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization Owners, directors, board members, corporate officers, LLC members/managers, and partners of the parent, grandparent, great grandparent, and etc. organization, if applicable Each individual having a beneficial interest of exceeding five percent or more in the applicant organization and/or parent, grandparent, great grandparent, and etc. organization Tips Page 2, section B — The date of birth is an identifier, as several people may have the same name. This will ensure that each individual is associated with the correct facility or entity Page 5, section E — Submit ten years of employment history, indicating the start and end dates of employment, job title, employer name and address. The applicant may submit a resume in lieu of completing section E; however, the resume must contain all required information requested in section E Page 7, section F — If answering yes to any question in this section, complete Section H: Facility Information Sheet
Supporting Documents	Facility Information Sheet Each individual must complete and submit the Facility Information Sheet for each facility and/or agency with which the individual has a current or past relationship within the last three years. This sheet must also include any facilities licensed by the California Department of Social Services. The following must be completed for each facility and/or agency: Facility name Facility address Type of facility Type of business entity (include EIN Number) Individual’s nature of involvement Individual’s dates of involvement
Supporting Documents	Resume [42 CFR section 485.705 (c)(1)] A resume is required for the Administrator
Supporting Documents	Bachelor’s Degree [42 CFR section 485.705(c)(1)] A bachelor’s degree is required for the Administrator
HS 309 1st Page (PDF)	Administrative Organization [42 CFR section 485.709(a)] Corporations complete page one Do not submit any attachments
HS 309 2nd Page (PDF)	Organizational Structure Only complete fields that are applicable to applicant’s entity type Tip Page 2, item 1 — Health care districts will fill in the circle for other
STD 850 (PDF)	Fire Safety Inspection Request [42 CFR section 485.723(a)(1)] The STD 850 form is required. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form

Medicare Certification Documents

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
CMS 1561 (PDF)	Health Insurance Benefits Agreement Submit two (2) signed forms with “original” signatures: Initial Application: Sign the top signature block entitled “Accepted for the Provider of Services By”
CMS 1856 (PDF)	Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy and/or Speech Pathology Services Submit a copy of the CMS 1856
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
Supporting Documents	Noridian Healthcare Solutions Recommendations of Approval Letter This letter is issued by Noridian Healthcare Solutions The letter should be included with the application packet
HS 328 (PDF)	Notice - Effective Date of Provider Agreement
HHS 690 (PDF)	Assurance of Compliance The Office of Civil Rights (OCR) online portal is: Office for Civil Rights (https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf) Once the online submission is completed, an electronic notification from OCR stating the Assurance of Compliance form was submitted successfully will be received by the applicant Submit a copy of this notification

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