HEALTH CARE FACILITY LICENSING AND CERTIFICATION

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

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

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

Primary Care Clinic - Affiliate

Initial 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.

Initial License
Medi-Cal

Checklist and Instructions - Please submit your documents in this order

Required Documents for an Initial License

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: Facility name and address Licensee physical 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 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) Signature
CDPH 611 (PDF)	Licensing and Certification for an Affiliate Primary Care Clinic Application [Title 22 California Code of Regulations (CCR) section 75021]
Supporting Documents	California Department of Health Care Access and Information (HCAI) [California Building Code Section 1226 and Health and Safety Code (HSC) Section 1217, 1218.1, 1226.3] and/or Certificate of Occupancy [CCR Section 75060] One of the three documents are required: Written certification: A California licensed architect or the local building authority must provide written certification of Title 24 compliance (OSHPD 3 Standards) stating the building meets the current applicable codes and the following building requirements: California Building Code (CBC) California Fire Code (CFC) California Electrical Code (CEC) California Mechanical Code (CMC) California Plumbing Code (CPC) California Administrative Code (CAC) CDPH 270: Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital, to certify the facility conforms to current applicable Title 24 (OSPHD 3 Standards). This form must be signed by a California licensed architect or local building authority Plan of Modernization: Approved by HCAI 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.1 – Organizational Chart – Owner Type [HSC section 1218.1] Submit an organizational chart for the nonprofit corporation. The organizational chart needs to display the following: Board members, corporate officers, and new directors (corporate officers as defined in the By-Laws) Note: Submit the HS 215A form for each new individual
Supporting Documents	F.1 – Control of Property [HSC section 1218.1(10)] Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed Licensee
HS 215A (PDF)	Applicant Individual Information [HSC section 1212(a), 1218.1] [22 CCR sections 75022, 75025] This form must be completed and signed for the following individuals: Administrator of the facility New directors, board members, and corporate officers of the applicant organization Note: Corporate officers as defined in the By-Laws 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 (except for the Administrator) 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 [22 CCR sections 75022(a)(4), 75045(d), 75046(b)] A resume is required for the Administrator
STD 850 (PDF)	Fire Safety Inspection Request [HSC section 1218.1(b)(9)] 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

Medi-Cal Certification Documents

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
DHCS 6207 (PDF)	Medi-Cal Disclosure Statement Only complete Section V
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 CDPH 611, item D.3 Notarized signature page is required Submit the “Acknowledgement” page from the notary public, if applicable
HS 269 (PDF)	Application for Medi-Cal Certification as a Primary Care Clinic Provider Complete, sign and date Tips The HS 269 form requires a National Provider Identifier number in lieu of the Medi-Cal provider number Page 1, question 4 - the specific type of service, advice, and treatment matches any other document included with your application Page 1, question 5 - list Medi-Cal as a source of funds
HS 328 (PDF)	Notice – Effective Date of Provider Agreement Submit one copy of the HS 328 form with original signature

Medicare Certification Documents

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

CMS 855B (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

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