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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

Initial and Change of Ownership 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
  • Change of Ownership (CHOW)
  • Medi-Cal

Checklist and Instructions - P​lease submit your documents in this order

Required Documents for an Initial License or CHOW 

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:

  • License number (only applicable for CHOW)
  • Facility name and 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
HS 200 (PDF)

Licensure & Certification Application

[Title 22 California Code of Regulations (CCR) section 75021]

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

​Supporting Documents

A.10 – California Department of Health Care Access and Information (HCAI) [California Building Code Section 1226 and Health and Safety Code (HSC) sections 1217, 1226.3] and/or Certificate of Occupancy [22 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 (OSHPD 3 Standards). This form must be signed by a California licensed architect or local building authority 

  • Plan of Modernization: Approved by HCAI

Note: Title 24 compliance does not apply to CHOWs unless there has been construction and/or remodeling.​

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.3 Organizational Chart – Owner Type

[HSC section 1212(a)]

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

  • ​Applicant’s directors, board members, and corporate officers (corporate officers as defined in the By-Laws) Note: Submit the HS 215A form for each of these individuals
  • ​Parent company of applicant, if applicable, and all of the licensed agencies/facilities it is operating- see B.6
​Supporting Documents 
B.3 Non-Profit Status – Owner Type

[HSC section 1204(a)(1)(A)(B)] [22 CCR section 75022(a)(3)]

Submit a copy of the IRS Tax Exempt Determination Letter showing the non-profit 501(c)(3) status

​Supporting Documents 

B.4.b License Revocation (if applicable)

Submit additional information, including all ownership and facility information, date and any final action

​Supporting Documents 

B.6 Organizational Chart

[HSC section 1212(a)]

If licensee is a subsidiary of another organization, an organizational chart must be submitted

Supporting Documents
D.1 – Control of Property

[HSC section 1212(a)]

Submit a 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)] [22 CCR, sections 75022]

This form must be completed and signed for the following individuals:

  • Administrator of the facility
  • Applicant Organization
    • Directors, board members, and corporate officers of the applicant organization
      Note: Corporate officers as defined in the By- Laws
  • Parent Company (if applicable)
    • ​​Directors, board members, corporate officers (as defined in the By-Laws) of the PARENT organization
​​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 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

[HSC 1212(a)] [22 CCR sections 75022(a)(4), 75045(d), 75046(b)]

A resume is required for the Administrator

HS 309 1st Page​ (PDF)


Administrative Organization
[22 CCR section 75022(a)(2)]
 
Along with the HS 309, depending on organizational type, the following supporting documents must be submitted:​

Supporting Documents​

Corporation

  • Filing Statement from the Secretary of State
  • Articles of Incorporation
  • By-Laws
  • List of Board of Directors (only if additional space is needed to input all board of directors)
Tip 
  • Page 1, item 3 — The incorporation date is located in the top right corner of the applicant Articles of Incorporation

HS 309 2nd Page​ (PDF)


Organizational Structure 

Only complete fields that are applicable to applicant’s entity type

Tip

  • Page 2, item 1 — Health care districts will fill in the circle for other
STD 850 (PDF)

Fire Safety Inspection Request

[22 CCR section 75061]

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.

  • ​This form is not required for a CHOW unless there has been construction and/or remodeling.


​​Required Documents for a CHOW Only​

Forms and Supporting Documents​​​

Additional Instructions

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

Supporting Docum​ents

In addition to the forms required for an Initial application listed above submit the documents requested below: [22 CCR sections 75021(3), 75055(e)]

  • Copy of Purchase Agreement or Operating Transfer Agreement
  • A letter from the prospective licensee (to CDPH) stating where the stored patient medical records will be maintained, and that the records will be made available to the previous licensee


​​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 8, item 3.c.1
  • 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


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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