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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
  • Contact Number​​​​​​​​​​​​​

Rehabilitation Clinic/Comprehensive Outpatient Rehabilitation Facility 

Report of Change Application Checklist for Change of Service

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.

Checklist and Instructions - Please submit your documents in this order

​Required Documents For a Change of Service 

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, 1.5MB)

Licensure & Certification Application

[Health and Safety Code (HSC) section 1212]


  • 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 HSC section 1226] and/or certificate of occupancy

For a newly licensed, constructed, or remodeled building, the following is required:

  • Title 24 compliance (OSHPD 3 Standards) - 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, is an acceptable form to certify the facility conforms to current applicable Title 24 (OSHPD 3 Standards). This form must be signed by the local building authority or HCAI. ​

  • Certificate of Occupancy 
Supporting Documents  

Floor Plan​

Submit a floor plan that describes the requested change of service including a schematic of each room.

STD 850​ (PDF) 

Fire Safety Inspection Request

[HSC 1225(c)(3)] [Title 42 Code of Federal Regulations (CFR) sections 485.62(a)(1), 485.723(a)(1)]​

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

Required Documents for Addition of Mobile Unit 

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

​Housing & Community
Development (HCD) Insignia 

Department of Housing & Community Development (HCD) Insignia
[HSC section 1765.120 through 1765.155]
  • Department of Housing and Community Development (HCD) Approval
    • Copy of HCD Inspection Approval, or
    • Copy of HCD Insignia​
​Vehicle Registration
Copy of Vehicle Registration

[HSC sections 1765.120 through 1765.155]

Submit copy of DMV registration documents, indicating:

  • Vehicle Identification Number (VIN)
  • Type of vehicle
  • Manufacturer
​Self-Contained Letter

Self-Contained Letter

[HSC sections 1765.120 through 1765.155]

  • Submit a letter or statement on cover 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
​Local Planning/Zoning Approval

Local Planning/Zoning Approval

[HSC sections 1765.120 through 1765.155]

  • 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
Medicare Certification Documents 

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

CMS 359​ (PDF) 

Comprehensive Outpatient Rehab Facility Report 

Submit the comprehensive outpatient rehab facility report for certifications

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