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Phone: (916) 552-8632

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

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 - P​lease submit your documents in this order

Required Documents for an Initial License

Forms and​ Supporting​​ Docume​​nts​​

​​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  (​
  • 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

B.1 – Organizational Chart – Owner Type

[Health and Safety Code (HSC) section 1218.1]

Submit an organizational chart for the nonprofit corporation. The organizational chart needs to display the following:

  • ​​Applicant's, directors, board members, and corporate officers
​Note: Submit the HS 215A form for each of these individuals if different from parent clinic

HS 215A (PDF)​

Applicant Individual Information

[22 CCR sections 75022, 75025] and [HSC sections 1212(a), 1218.1]

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
  • 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 included 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 


[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 sections 1218.1(b)(9), 1765.155(a)]

  • 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
  • If the STD 850 form is not required for a particular mobile clinic, a written statement from the local fire agency must be submitted

Required Documents for a Mobile Clinic

Forms and Supporting Documents​​​

Additional Instructions

(Each for​​m listed also has instructions on the form) ​

​Supporting Documents

In addition to the above Initial application forms, a PCC – Affiliate Mobile must submit the documents requested below: [HSC sections 1765.20(a), 1765.20(b), 1765.150(b), 1765.155(a)]

  • A copy of the DMV vehicle registration showing ID, type and manufacturer
  • Department of Housing & Community Development (HCD) Approval
    • Copy of HCD Inspection Approval, or
    • Copy of HCD Insignia
  • A letter verifying the mobile unit is self-contained
    • If the mobile unit is not self-contained, HCAI approval is only required if the utility hookups originate or pass through any general acute care hospital building
  • The Local Planning/Zoning approval
    • Submit a copy of the Local Planning/Zoning approval
    • If the Local Planning/Zoning approval is not required for a particular mobile clinic, CAB needs a written statement from the Local Planning/Zoning agency

​​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


  • The HS 269 form require​s 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​

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