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:

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 Mobile

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 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 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
Days and hours of operation
Locations serviced by mobile unit
Contact information (name, title, phone number, and
email 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: California Health Alert Network (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

HS 200 (PDF, 1.5MB)

Licensure & Certification Application

[Title 22 California Code of Regulation (CCR) section 75022]

[Health and Safety Code (HSC) section 1212]

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

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 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

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