Skip Navigation LinksPCC-Consolidated-Mobile-CHOL-Provider-Checklist

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 - Consolidated Mobile

Report of Change Application Checklist for Change of Location

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 Location

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: 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 75021] [Health and Safety Code (HSC) section 1765.130]

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 
STD 850 (PDF) 

Fire Safety Inspection Request

[HSC section 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 ​
​Self-Contained Letter

Self-Contained Letter

[HSC section 1765.150]

  • 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
​Local Planning/Zoning Approval

Local Planning/Zoning Approval

[HSC section 1765.155]

  • 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 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, section C, Page 3, item 4
  • Notarized signature page is required
  • Submit the “Acknowledgement” page from the notary public
HS 269 (PDF) 

Application for Medi-Cal Certification as a Primary Care Clinic Provider 

Complete, sign, and date

Tips

  • A Change of Ownership means the non-profit corporation owning and operating the primary care clinic does not share the same federal tax identification number as the previous number 
  • 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 


​​
Page Last Updated :