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

Skilled Nuring Facility or Intermediate Care Facility: Medi-Cal Certification
Applicant Checklist

The forms and information are required for Medi-Cal certification​. Note: All forms listed are in PDF format.

​Form #Description​Check List​
HS 328

Notice - Effective Date of Provider Agreement

  • If applying for both Medi-Cal & Medicare certification, only need one copy of this form.​
DHCS 6207

​Medi-Cal Disclosure Statement​

NOTE: Only complete section V.

​DHCS 9098

​Medi-Cal Provider Agreement

  • Do not leave questions blank. Enter N/A or "same" if not applicable.
  • The "mailing address" must be the same as reported on the HS 200 form, page 3, Item 4.
  • Signature page must contain original signatures.
  • Submit the "Acknowledgement" page from the Notary Public, if applicable.


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