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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: Non-Urbanized Area Determination
Applicant Checklist

The following is a quick reference of some of the questions found on the required forms. It includes the form number, name of form, and an explanation of specific requirements and/or attachments needed for specific forms. This is not an all-inclusive list of the questions that need to be answered so read the questions and instructions on each form.

Note: All forms listed are in PDF format. 

Form #​DescriptionCheck List
HS 610

Medically Underserved or Health Professional Shortage Areas

  • This form is to see if you qualify as a RHC – census tract number.
  • This form does not need to be submitted for a change of ownership (CHOW).
  • If you are already licensed as a PCC and want to be certified as a RHC, submit to the appropriate district office.
  • If you are not licensed as a PCC and want to be certified as a RHC, submit to the Centralized Applications Branch.
  • If applying for both Medi-Cal & Medicare certification, only need one copy of this form.
CMS 29

​Request to Establish Eligibility

  • This form is required for both "initial" and CHOW applications.
  • If you are already licensed as a PCC and want to be certified as a RHC, submit to the appropriate district office.
  • If you are not licensed as a PCC and want to be certified as a RHC, submit to the Centralized Applications Branch.
  • If applying for both Medi-Cal & Medicare certification, only need one copy of this form.


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