HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Rural Health 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 Certification
Change of Ownership (CHOW)
Medi-Cal
Medicare

Checklist and Instructions - Please submit your documents in this order

Applicants seeking initial certification as an RHC must be located in a non-urbanized area and in a medically underserved area (MUA) or health professional shortage area (HPSA). The Centralized Application Branch (CAB) makes a preliminary assessment based on the information contained in the application packet. The Centers for Medicare and Medicaid Services (CMS) makes the final determination whether the location qualifies and meets all applicable Federal requirements.

Required Documents for an Initial Certification

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 (only applicable for CHOW) Facility name and address Facility ID number (if known) Brief description of request Applicant Contact Information (name, title, phone number, applicant contact email address) The Department will use the applicant contact email address to send all application correspondence General Contact Information (name, title, phone number, fax, email address, and alternative contact information) The Department will use this information to contact the facility for day-to-day business Emergency Contact Information (name, phone number, fax, email address, alternate email, 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 All Facility Letter Contact Information (name, phone number, fax, and email address) The Department will use this information to send All Facility Letters Facility Contact (Public Use) Information (phone number, fax, email address, and website address) The Department will use this information to store facility contact information for the public Privacy Officer Contact Information (name, title, mailing address, phone number, and email address) The Department will use this information to correspond with the facility’s Privacy/Compliance Officer regarding medical breach incidents Signature
HS 610 (PDF)	Medically Underserved or Health Professional Shortage Areas (Not required for a CHOW) [Title 42 Code of Federal Regulations (42 CFR) section 491.5] Clinic name and address Census track number Note: Census track number can be found by going to the Federal Financial Institutions Examination Council. You may contact the FFIEC for any questions regarding the census track number.
CMS 29 (PDF)	Verification of Clinic Data – Rural Health Clinic Program [42 CFR section 491.7(a)(1), 491.8(a)(2)] If applying for both Medi-Cal & Medicare Certification, only need one copy of this form Provided name and title of individual in charge of Medical Direction of the facility. This individual must have a physician’s license
HS 200 (PDF, 1.5MB)	Licensure & Certification Application [42 CFR 420 Subpart C, and 455 Subpart B] 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	B.3– Organizational Chart – Owner Type [42 CFR section 491.7] Submit an organizational chart if the owner is a for profit corporation, nonprofit corporation, limited liability company (LLC), or general partnership. The organizational chart needs to display the following: Applicant’s owners, including ownership percentages, Tax IDs/EINs and all directors, board members, corporate officers, LLC members/managers, and/or partners 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 Submit a copy of the IRS Tax Exempt Determination Letter showing the non-profit 501(c)(3) status (if applicable)
Supporting Documents	B.6 – Organizational Chart If licensee is a subsidiary of another organization, an organizational chart must be submitted
HS 215A (PDF)	Applicant Individual Information [42 CFR sections 420.206(a)(3), 455.104, 491.7] This form must be completed for the following individuals: Administrator of the facility Each individual having a beneficial interest of exceeding five percent in the applicant organization and/or parent organization Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization and/or Management Company 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 and attach the facility information sheet.
Supporting Documents	Facility Information Sheet Each individual (except for the Administrator) 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 A resume is required for the Administrator
HS 309 1st Page (PDF)	Administrative Organization If applying for both Medi-Cal and Medicare Certification only need one copy of this form Administrator of Corporation or LLC is usually the Chief Executive Officer or President Corporations complete page one Do not submit any attachments
HS 309 2nd Page (PDF)	Organizational Structure Only complete fields that are applicable to applicant’s entity type

Required Documents for a CHOW Only

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

Supporting Documents

In addition to the forms required for an Initial application listed above in addition to the documents requested below:

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 affirming records will be made available to the previous licensee
Copy of “Interim Management Agreement” (If Applicable)

Medi-Cal Certification Documents

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

DHCS 9098 (PDF, 2.9MB)

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, if applicable

HS 328 (PDF)

Notice – Effective Date of Provider Agreement

If applying for both Medi-Cal and Medicare certification, only submit one copy of this form

Medicare Certification Only 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
CMS 1561A (PDF)	Health Insurance Benefit Agreement – Rural Health Clinic Two (2) signed copies with “original” signatures
HHS 690 (PDF)	Assurance of Compliance OCR’s online portal is:Office for Civil Rights Submit a copy of the notification stating the “Assurance of Compliance from was submitted successfully”