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 and Intermediate Care 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 both Medi-Cal and Medicare 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/post/california-health-alert-network-cahan) Contact Information for the Privacy Officer or Designee responsible for submitting and responding to medical breach incidents (name, title/position, mailing address, phone number, and email address) Signature
HS 200 (PDF, 1.5MB)	Licensure & Certification Application Note: If applying for Med-Cal, applicant must complete the “Subcontractor Information and Significant Business Transactions” attachment Tips: Page 6, section B, item 6 — An organization will have its own Federal tax ID number
CMS 671 (PDF)	Long Term Care Facility Application for Medicare & Medicaid Original signature is required on this form.
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 7, Section C, Item 2.c. 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 855A (PDF)	Medicare Enrollment Application (Institutional Providers) This application is from the Federal Department of Health and Human Services The completed application should be mailed directly to the appropriate fiscal intermediary This document does not go to CAB
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: U.S. Department of Health and Human Services (https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf)

Page Last Updated :

What’s New

Administrative

Diseases and Conditions

Family Health

Health and Safety

Health Facilities

Personal Health and Prevention

Licensing, Certification and Other Credentials

Person Interested In