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

Primary Care Clinic: Rural Health Clinic ​- Medicare Certification (Non-Urbanized Area)
Applicant Checklist

The following forms and information are required for rural health clinic (RHC) Medicare certification for a licensed free-standing primary care clinic (PCC).  Note: All forms listed are in PDF format. 

Form #​DescriptionCheck List

​HS 328

​Notice – Effective Date of Provider Agreement
  • If applying for both Medi-Cal & Medicare certification, only need one copy of this form.

CMS 855A

​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.

​CMS 1561

​Health Insurance Benefit Agreement

Submit two (2) signed copies with "original" signatures.

​​OMB No. 0990-0243​Civil Rights Information Request for Medicare Certification
  • Complete and "sign" form (original signature).
  • Submit copy of all items required on the form.
  • All 9 items need to be "identified" and accounted for; however, if less than 15 employees, Item #6 does not apply.
  • DO will not review these items since they are to be approved by OCR.

​HHS 690

​Assurance of Compliance

  • Submit 1 copy. This HHS 690 form is the first document required to be submitted on the above OMB No. 0990-0243 form.

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