HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Hospice Agency, Home Health Agency (HHA), Skilled Nursing Facility (SNF)

Medi-Cal Revalidation 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.

Checklist and Instructions - Please submit your documents in this order

Required Documents for a Revalidation

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 ID number (if known) Brief description of request Indicate if the facility requests a revalidation or a voluntary withdrawal If the facility chooses to voluntarily withdraw, the provider must submit a voluntary withdrawal letter If the facility chooses to revalidate, indicate if the facility has been revalidated by CMS in the last 12 months and provide the date of CMS revalidation If the facility chooses to revalidate and has already paid a revalidation fee in the last 12 months for Medicare or Medicaid (in another state) provide the proof of payment Applicant Contact Information (name, title, phone number, 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 (https://www.calhospitalprepare.org/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 200 (PDF, 1.5MB)	Licensure & Certification Application [42 CFR 455.412, 455.104 & 455.107] Only fill out the following sections on the HS 200 for revalidation: Page 1, section A, item 4 - select the type of facility, agency, or clinic Page 2, section A, item 5 - If you are enrolled in the Medicare program at this business address and under this legal name enter the Medicare Provider #, and National Provider Identifier (NPI) Page 2, section A, item 6 - If you are enrolled in the Medi-Cal (Medicaid) program, complete section F. Subcontractor Information and Significant Business Transactions and enter National Provider Identifier (NPI) Pages 3-6, section B Pages 7-11, section C, item 1, item 2, item 4, and item 5. Pages 12-23, sections E-G Tips: Page 3, section A, item 9 – If the facility, agency, or clinic indicates they operate 24/7/365, complete “b" to indicate the hours of operations for the public. This information is used for surveying purposes Page 3, section B, item 2 – Provide the EIN of the licensee. Do not enter the Social Security number in this field Page 6, section B, item 6 – An organization must own 100 percent of the licensee to be considered a parent company. This parent company will have its own Employer Identification Number (EIN) Page 9, section C, item 5 – When listing the names of individuals with direct or indirect ownership of the facility in section C, provide the EIN (do not enter a Social Security number in this field)
Supporting Documents	IRS – Internal Revenue Service Documentation Submit one of the following IRS tax documents showing entity's legal name and Tax Identification Number: Form 941 - Employer's Quarterly Federal Tax Return Form 8109 - C FTD Address Change Letter 147-C - EIN Confirmation Notification Form SS-4 - Confirmation Notification
Supporting Documents	B.3 - Organizational Chart - Owner Type 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 Parent company of applicant, if applicable, and all the licensed agencies/facilities it is operating - see B.6 Note: Submit the HS 215A form for each of these individuals
Supporting Documents	D.1 - Control of Property Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee.
HS 215A (PDF)	Applicant Individual Information [42 CFR 455.412, 455.104, 455.106 & 455.107] This form must be completed and signed for the following individuals: Administrator and the Director of Patient Care Services of the facility Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization Each individual having a beneficial interest of five percent or more in the applicant organization and/or parent organization Tip: Page 2, section B, item 3 — The date of birth is an identifier, as several people may have the same name. This will ensure each individual is associated with the correct facility or entity Page 2, section B, item 4 – Provide your Driver's License Number or a State-Issued identification Card Number. Attached a copy of the Driver's License or State-Issued Identification Card for verification. Page 2, section B, item 5 – The Social Security Number is an identifier, as several people may have the same name; this will ensure each individual is associated with the correct facility or entity Page 3, section B, item 7 – Administrator must list the number of hours spent at each agency per week 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 D; 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 section H – Facility Information Sheet
Supporting Documents	Facility Information Sheet Each individual 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 and Director of Patient Care Services.
HS 309 1st Page (PDF)	Administrative Organization [42 CFR 455.104] Along with the HS 309, the following supporting documents according to organizational type must be submitted:
Supporting Documents	Corporation Filing Statement from the Secretary of State Articles of Incorporation By-Laws List of Board of Directors (only if additional space is needed to input all board of directors) Tip: Page 1, item 3 — The incorporation date is in the top right corner of the applicant Articles of Incorporation
Supporting Documents	Limited Liability Company (LLC) Filing Statement from the Secretary of State Articles of Organization Operating Agreement List of Managing Members (only if additional space is needed to input all managing members)
HS 309 2nd Page (PDF)	Organizational Structure [42 CFR 455.104] Only complete fields that are applicable to applicant’s entity type.
Supporting Documents	Public Agency Copy of signed Resolution
Supporting Documents	Partnership Copy of signed Partnership Agreement
CDPH 322 (PDF)	Transmittal Application for Criminal Record Clearance [42 CFR 455.434, 455.450 & 455.104] Submit the CDPH 322 form for the following individuals: Owners with a five percent or more direct or indirect ownership Administrator Note: Mail this form to the address indicated on the form
CDPH 325 (PDF)	Criminal Record Clearance Submissions [42 CFR 455.434, 455.450 & 455.104] Submit the CDPH 325 form with for the following individuals' names listed on the form: Owners with a five percent or more direct or indirect ownership Administrator
HS 328 (PDF)	Notice – Effective Date of Provider Agreement [42 CFR 431.107] If applying for both Medi-Cal and Medicare certification, only submit one copy of this form.
DHCS 9098 (PDF, 2.9MB)	Medi-Cal Provider Agreement [42 CFR 431.107, 455.104 & 455.107] 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 Notarized signature page is required Submit the "Acknowledgement" page from the notary public, if applicable
BCIA 8016 (PDF, 1.3MB)	Request for Live Scan Service For out-of-state fingerprint clearance, contact the Centralized Applications Branch at (916) 552-8632 or by e-mail: CAB@cdph.ca.gov Instructions for completion of the BCIA 8016 form are available on the Attorney General's website (https://oag.ca.gov/fingerprints) The ORI# must be "A1226." Submit the BCIA 8016 form for the following individuals: Owners with a five percent or more direct or indirect ownership Managing personnel