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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

Licensure Application Forms​

 


The following documents are required to apply for:

  1. an initial (new) license; 
  2. a change of ownership (CHOW);
  3. to operate a mobile clinic; 
  4. a license as an affiliate clinic; 
  5. to operate an affiliate clinic mobile unit; 
  6. a consolidated license; or, 
  7. a consolidated license mobile clinic.

Note: The “X” denotes the required forms specific to the type of licensure/certification for which you are seeking. If the box is blank, that particular form is not required to be completed.

Note: If you are also applying for Medi‑Cal and/or Medicare certification, see page 8 for the required forms and/or documents required for certification.

Form # Form Name​ PCC - Initial​ PCC - CHOW​ PCC - Mobile​ PCC - Mobile CHOW​ Affiliate​ Affiliate CHOW​ Affiliate Mobile​ Affiliate Mobile Chow​ Consolidated license​ Consolidated Mobile​
HS 200 (PDF)
Instr  Cklst
​Licensure & Certification Application


​X


​X

​X

​X
​Suppl DocSupplemental Application Documents
​X

​X

​X

​X

X

​X

​X

​X

​X

​X
HS 215A (PDF)
Instr Cklst
​Applicant Individual Information
​X

​X

​X

​X

​X

*


​X

​X

*


​X

HS 309 (PDF)

Instr Cklst

Administrative Organization
​X

​X

​X

​X
STD 850 (PDF)
Cover Letter
Fire Safety Inspection Request
​X

​X

​X

​X

​X

​X

​X

​X
CDPH 270 (PDF)​Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital

​X


​X


​X
CDPH 611 (PDF)​Licensing and Certification for an Affiliate Primary Care Clinic Application
Note: the full legal name of the applicant corporation names must be used as filed with the Secretary of State and consistently used throughout the application.

X​

X​

X​

X​
* HS 215A is only required for new administrators of Affiliate/Affiliate Mobile PCC​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​

 



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