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EDMUND G. BROWN JR.
Governor

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



​Rural Health Clinic: Medicare Certification "Only" (Non-Urbanized Area)
Applicant Checklist

 The following forms and information are required for a rural health clinic (RHC) Medicare certification.  Note: All forms listed are in PDF format.

Form #​Item #​Description​Check List

HS 200 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​

​Gen Info

Licensing & Certification Application

  • Please read the instructions on the HS 200 form prior to completing the form. The items listed below are the most common items that are not completed correctly; however, these are not all of the items listed on each form.
  • Only complete the HS 200 form if the rural health clinic (RHC) is not licensed as a primary care clinic (PCC).
  • If applying for both Medi-Cal and Medicare certification, only need one copy of the HS 200 form.
  • Do not send copies of the lease or etc. since the Centralized Applications Branch (CAB) only needs this form for input purposes.

 

​​A.11.Construction 
  • If requested, reports demonstrating compliance with local building, fire, safety codes "should be available for review."
​B.1

​Licensee's Name

  • The licensee's formal organization name must be consistent throughout all documents.
​​B.3.​​Owner type

Submit an organization chart/flow chart if the owner is a profit or nonprofit corporation, limited liability company (LLC), or general partnership. The organization chart needs to display the following:

  • Applicant’s owners and ownership percentages, directors, board members, corporate officers, LLC members/managers, and 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 they are operating – see B.6.
​B.5.a.​Licensee’s "other" facility involvement
  • Answer all aspects of the question.
​​B.6.​Subsidiary (Parent Company) Information

If there is a “subsidiary” (parent company) submit:

  • An organization chart with the parent company name.
  • A listing of all owners and ownership percentages, directors, board members, corporate officers, LLC members/managers, and partners of the parent company.
    Note: Submit the HS 215A form for each of these individuals.
  • A listing of all facilities the parent company is operating.
​​C.1.b​"Interim" Management Company Agreement
  • Note if CHOW: If there is an "interim" Management Company Agreement, between the current and the prospective licensee, submit a signed and dated copy of Agreement.
​​C.2.​Name of "Proposed" and "Current" Facility
  • Enter both facility names if this is a CHOW.
​​C.6.a​Administrator
  • Enter the name of administrator.
​​C.7.​Ownership
  • List all individuals having 5% or more ownership, unless "nonprofit."
  • Submit the HS 215A form for each of these individuals.
​D.1.
D.2.
​Property Ownership
  • Complete this portion of the HS 200 form.
​​F.1.​Signature
  • Original "signature" is required and must be signed by the applicant (not the administrator unless the owner is the administrator).

HS 215A​ ​ ​ ​

​Gen Info

​Applicant Individual Information 

  • Only complete the HS 215A if the RHC is not licensed as a PCC. 
  • If applying for both Medi-Cal & Medicare certification, only need one copy of this form.
  • Please read the instructions on the HS 215A form prior to completion of the form.
  • This form must be completed for the following individuals with original signatures:
    • Administrator of the facility with his or her resume
    • Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization and/or parent company.
​​Sign

​Signature

  • Original "signature" is required.

HS 309 1st page ​ ​ ​ ​

​Gen Info

​​ ​Administrative Organization ​

  • Only complete the HS 309 form if the RHC is not licensed as a PCC.
  • If applying for both Medi-Cal and Medicare certification, only need one copy of this form.
  • Do not send any corporation, LLC, or etc. attachments since CAB only needs this form for input purposes.
  • Read the instructions on the HS 309 form prior to completion of the form.
​2.​Administrator of Corporation or LLC – This is usually the CEO/President.
​3. - 7.​Corporations need to submit:
  • List of board of directors - submit the HS 215A form for each individual listed under this item.

LLCs need to submit:

  • List of members, holders, officers, managers - submit the HS 215A form for each individual listed under this item.
​9.​Governing Board of Directors
  • Enter the number of members/managers.
  • Submit the HS 215A form for each individual listed under this item.
​10.​Board Officers and/or LLC Members/Managers
  • Enter the number of members/managers.
  • Submit the HS 215A form for each individual listed under this item.

HS 309

2nd page ​ ​ ​ ​
​Organizational Structure ​[Title 22 CCR Section 75022(a)(2)]
​1.​California Out-of-State Corporations, LLC, etc.
​5.​​Corporations, LLCs, and Partnerships need to complete. N/A for nonprofit.
​Bottom of page​​Partnerships need to submit:
  • HS 215A form for each partner listed.

STD 850

​Fire Safety Inspection Request
  • The STD 850 form is not required; however, if requested, reports demonstrating compliance with local building, fire, and safety codes "should be available for review."

​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.
​CHOW​Change of Ownership (CHOW)

Submit the following:

  • All of the forms required for an "initial" certification listed above.
  • 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.


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