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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health



​Primary Care Clinic

Form HS 200

 

The following table identifies the section/item # that require completion for licensure and/or certification denoted by the “X” in that field. If the field is blank, that section/item does not need to be completed. Please complete all items and provide all requested supplemental documents. Do not leave any items blank. If a question does not apply, respond with “Not Applicable” or “N.A.”.

Section / Item #​PCC InitialPCC CHOW​PCC Mobile​PCC Mobile CHOW​Affiliate​Affiliate CHOW​Affiliate Mobile​Affiliate Mobile CHOW​Consoldtd License​Consoldtd Mobile​
A. APPLICATION INFORMATION ​ ​ ​
​A.1 – Type of Application​XX​X​X​X​X​
​A.2 – Change of Ownership Only – For Certification Purposes​X​X
​A.3 – Amount of fee enclosed​XX​X​X​​X​X
​A.4 – Type of Change​X​X​X​X​X​X
​A.5 – Type of facility, agency, or clinic​X​X​X​X​X​X
​A.6.a – Applying for Medicare program​X​X​X​X​X​X
​A.6.b – Fiscal Intermediary​X​X​X​X​X​X
​A.7 – Applying for Medi-Cal program​X​X​X​X​XX​
​A.8.a – Current facility bed capacity
​A.8.b – Proposed facility bed capacity
​A.9 – Age range of clientsX​​XX​​X​X​X
​A.10 – Days and hours of operation​X​X​XX​​X​X
​A.11 – Is construction required​XX​​X
​B. LICENSEE INFORMATION ​ ​ ​ ​ ​ ​ ​ ​ ​ ​
​B.1 – Licensee Name​X​XX​​XX​​X
​B.2 – Federal employer’s tax ID number​X​X​X​X​X​X
​B.3 – Owner type​X​X​X​X​X​X
​B.4 – Licensee address​X​X​X​X​X​X
​B.5.a – Identify other facilities, agencies, or clinics​X​X​X​X​X​X
​B.5.b – License revocation action filed, license placed on probation, suspended, or revoked, settlement, receiver appointed, Medi-Cal decertification​X​X​X​X​X​X
​B.6 – Is the licensee a subsidiary of another organization​XX​​XX​​XX​
C. FACILITY, AGENCY OR CLINIC INFORMATION ​ ​ ​ ​ ​ ​ ​ ​ ​ ​
​C.1.a – Management Agreement (Only for SNF’s & ICF’s)

"Not Applicable"

​C.1.b – “Interim” Management Agreement (if applicable)​X​X​XX​
​C.2 – Name of “Proposed” facility, agency, or clinic and “Current” facility, agency, or clinic name if change of ownership​XX​​XX​​X​X

​C.3 – Address of “proposed” facility, agency, or clinic

Note: You must use the 9-digit zip code for this address.

​X​X​X​X​X​X
​C.4 – Mailing address, if different​X​X​X​X​X​X
​C.5 – Name of person to be in charge of facility, agency, or clinic (i.e., medical director)​X​X​X​X​X​X
​C.6.a – Name of administrator​X​XX​​XX​​X
​C.6.b – Name of director of nursing

"Not Appicable"

​C.7 – List of persons have 5 percent or more direct or indirect interest of the ownership

"Not Applicable"

​C.8 – Financial resources (Only applies to SNF’s & ICF’s)

"Not Applicable"

​C.9 – Over-concentration (Only applies to ICF/DD, ICF/DD-H, and ICF/DD -N)

"Not Applicable"

​C.10 – Program Plan (Only applies to ICF/DD, ICF/DD-H, and ICF/DD -N)

"Not Applicable"

D. PROPERTY INFORMATION ​ ​ ​ ​ ​ ​ ​ ​ ​ ​
​D.1 – Property Ownership​X​X​X
​D.2 – Owner of Record​X
E. MANAGEMENT COMPANY ​ ​

"Not Applicable"

​F. – Signature: (Original signature required)

Note: Sign in “BLUE” ink

​X​X​X​X​X​X

 



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