HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Contact Us

Phone: (916) 552-8632

For application status requests, please include the following in your email:

Application ID (if applicable)
Name of Facility or Agency
License or Facility/Agency # (if applicable)
Address
Facility or Provider Type
Date Documentation Sent
Contact Number

Skilled Nursing Facility

Report of Change Application Checklist for Change of Certification

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.

Medi-Cal
Medicare

Checklist and Instructions - Please submit your documents in this order

Required Documents for a Change of 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 Facility name and address Facility ID number (if known) Brief description of request to add Medicare [Title 18] and/or Medi-Cal [Title 19] 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 (https://www.calhospitalprepare.org/cahan) Signature
CMS 671 (PDF)	Long Term Care Facility Application for Medicare and Medicaid Original signature required on this form
HS 200 (PDF, 1.5MB)	Licensure & Certification Application [Health and Safety Code (HSC) Section 1212] Page 3, 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 7, Section C Tip: Page 9, Section 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 on the HS-200 form) Page 17, Attachment F–1
HS 328 (PDF)	Notice - Effective Date of Provider Agreement If applying for both Medi-Cal & Medicare certification, only submit one copy of this form

Medi-Cal Certification Documents

Forms and Supporting Documents

Additional Instructions
(Each form listed also has instructions on the form)

DHCS 9098 (PDF)

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, page 3, section C, item 4

Notarized signature page is required
Submit the “Acknowledgement” page from the notary public

Medicare Certification Documents

Forms and Supporting Documents

Additional Instructions
(Each form listed also has instructions on the form)

CMS 1561 (PDF)

Health Insurance Benefit Agreement

Submit two (2) signed copies:

Sign the bottom signature block entitled “Accepted for the Successor Provider of Services By”

HHS 690 (PDF)

Assurance of Compliance

Office of Civil Rights requires the HHS 690 form be submitted.

Receive confirmation of online submission: https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf

Page Last Updated :

COVID-19

Diseases and Conditions

Licensing, Certification and Other Credentials

Family Health

Personal Health and Prevention

Health and Safety

Health Facilities

Administrative

Person Interested In

HEALTH CARE FACILITY LICENSING AND CERTIFICATION​