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EDMUND G. BROWN JR.
Governor

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



Skilled Nursing Facility: Medicare Certification
Applicant Checklist

The following forms and information are required for Medicare 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.
CMS 671​

​Long Term Care Facility Application for Medicare and Medicaid

1st page:

  • Item A.F9 is "03" if you want both Medi-Cal and Medicare.
  • If Item F12 is an "LLC", insert "03", which is for corporations and LLCs.
  • Items F28 & F30 and F29 & F31 are required to be completed. Enter N/A, if not applicable.

2nd page: Facility Staffing Form:

  • Enter staff hours worked in the most recent complete pay period.
  • Enter either a "Y" (for yes) or "N" (for no) under Column A, sub-columns 1, 2 and 3 in the "unshaded" areas. If youhave entered "Y", enter hours in the appropriate "unshaded" areas.
  • Original signature required along with the time and date form was completed.
CMS 855A

​Medicare General Enrollment Health Care Provider/Supplier Application

  • This application is from the Federal Department of Health and Human Services.
  • The completed application should be mailed directly to the appropriate Fiscal Intermediary.
CMS 1561

​Health Insurance Benefit Agreement

Submit two (2) signed copies with "original" signatures.

  • Initial Application: Sign the top signature block entitled "Accepted for the Provider of Services By."
  • CHOW: Sign the bottom signature block entitled "Accepted for the Successor Provider of Services By."
​OMB No. 0945-0006

​Civil Rights Information Request for Medicare Certification

  • Complete and "sign" form (original signature).
  • Submit all of the documents required on Part 11 of this OMB form. All of these documents need to be "identified "by the corresponding number on the OMB form. The first document required is the HHS 690 form below.
  • These items will be reviewed and approved by OCR.
HHS 690

​Assurance of Compliance

  • Submit 1 copy. This HHS 690 form is the first document required to be submitted on the above OMB No. 09450006 form.

 



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