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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
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Primary Care Clinic - Mobile

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 - Please submit your documents in this order

Required Documents for an Initial or CHOW

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
  • 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
HS 200 (PDF, 1.6MB) 

Licensure & Certification Application

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


  • 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

B.3 - Organizational Chart – Owner Type

[Health and Safety Code (HSC) 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 they are 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

HS 215A (PDF)

Applicant Individual Information

[HSC section 1212(a)] [22 CCR sections 75022]

This form must be completed for the following individuals:

  • Administrator of the facility
  • Applicant Organization
    • Directors, board members, corporate officers (CEO, President, COO, CFO), LLC members/managers and partners of the applicant organization
  • Parent Company (if applicable)
    • Directors, board members, corporate officers, LLC members/managers, and partners of the PARENT 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 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


[HSC section 1212(a)] [22 CCR section 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, the following supporting documents according to organizational type must be submitted:

Supporting Documents 

  • Articles of Incorporation endorsed by CA Secretary of State
  • Filing Statement from CA Secretary of State (only if Articles of Organization are not endorsed by the CA Secretary of State)
  • By-Laws stating size of the Board
  • List of Board of Directors (only if additional space is needed to input all board of directors)
  • Page 1, item 3 — The applicant can find the incorporation date located in the top right corner of the Articles of Incorporation
HS 309 2nd Page (PDF)

Organizational Structure

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


  • Page 2, item 1 — Health care districts will fill in the circle for other
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

Required Documents for a Mobile Clinic 

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form) 

Supporting Documents 

In addition to the above Initial application forms, a PCC –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 & 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

Required Documents for a CHOW Only

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

Supporting Documents 
All of the forms required for an Initial application listed above in addition to 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 HS 200 form, section C, Page 8, item 3.c.1
  • 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


  • 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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