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HEALTH CARE FACILITY LICENSING AND CERTIFICATION

 Contact Us

Phone: (916) 552-8632
Email: CAB@cdph.ca.gov    

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

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

Surgical Clinic and Surgical Clinic/Ambulatory Surgery Center

Initial and Change of Ownership 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.

  • Initial License
  • Change of Ownership (CHOW)
  • Medicare
  • Medi-Cal

Checklist and Instructions - P​lease submit your documents in this order

Required Documents for an Initial License or CHOW

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 (only applicable for CHOW)
  • Facility name and address
  • Facility ID number (if known)
  • Brief description of request
  • 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)
  • 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)

Licensure & Certification Application

[Health and Safety Code (HSC) section 1212]

Tip

  • Attachment F-1 – If the current or proposed facility, agency, or clinic is applying for Medi-Cal certification, complete Attachment F-1: Subcontractor Information and Significant Business Transactions
​Supporting Documents

A.10 – California Department of Health Care access and Information (HCAI) and/or Certificate of Occupancy

[Title 24 California Code of Regulations (CCR) part 2 sections 111 and 1226.2] [HSC section 1226]

One of the two documents are required:

  • Written certification: The local building authority must provide written certification of Title 24 compliance (OSHPD 3 Standards) stating the building meets the current applicable codes and the following building requirements:

    • California Building Code (CBC)
    • California Fire Code (CFC)
    • California Electrical Code (CEC)
    • California Mechanical Code (CMC)
    • California Plumbing Code (CPC)
    • California Administrative Code (CAC) 

CDPH 270: Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital, to certify the facility conforms to current applicable Title 24 (OSHPD 3 Standards). This form must be signed by the local building authority

Note: Title 24 compliance does not apply to CHOWs unless there has been construction and/or remodeling

If construction occurred and if the construction resulted in a new building or addition:

  • Submit a Certificate of Occupancy
  • This is not applicable if there were alterations or repairs to existing buildings performed or conversion of space

​Supporting Documents

B.3 Organizational Chart - Owner Type

[HSC section 1212]

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 entity
​Licensed-Only SURGC
  • Applicant’s direct and indirect owners with 10 percent or more ownership interest in the applicant entity (include ownership percentages)
  • ​Officers and directors of applicant and any entity with 10 percent or more ownership interest in the applicant
​Licensed and Certified SURGC/ASC
  • Applicant’​s direct and indirect owners with five percent or more ownership interest in the applicant entity (include ownership percentages)
  • Officers and directors of applicant and any entity with five percent or more ownership interest in the applicant 

Note: Submit the HS 215A form for each of these individuals

Management company, if applicable

  • Owners, officers, and directors
All other licensed and/or certified facilities operated by applicant’s parent company and/or management company, if applicable
Supporting Documents
B.4.b License Revocation (if applicable)

[HSC section 1212]

Submit additional information, including all ownership and facility information, date, and any final action

​Supporting Documents
B.6 Organizational Chart

If licensee is a subsidiary of another organization, an organizational chart must be submitted

​Supporting Documents 
B.3 – Internal Revenue Service Documentation

[HSC section 1212]

Submit one of the following IRS tax documents showing the 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 
C.1.a – Management Company Agreement (If

applicable)

[HSC section 1212]

Facilities operated under a Management Agreement between the licensee and a management company must complete and submit Attachment E-1 (Management Company Information) and submit a copy of the Management Agreement

The Management Agreement must state that the licensee is responsible for the Facility

​Supporting Documents 

D.1 Control of Property

[HSC section 1212]​

Submit a copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed Licensee

​Supporting Documents 
Floor Plan

[HSC section 1212]

Submit a floor plan that coincides with your office space

HS 215A (PDF)​

Applicant Individual Information [Title 42 Code of

Federal Regulations (CFR) section 455 subpart B and 420 subpart C] [HSC section 1212]

This form must be completed for the following new individuals:

  • Administrator of the facility
  • Parent Company (if applicable)
    • Directors, board members, corporate officers of the PARENT organization
  • Owners, officers, directors of management company, if applicable
 
​Licensed-Only SURGC
 
  • Individual direct and indirect owners with 10 percent or more ownership interest in the applicant entity
  • Officers and directors of applicant and any entities with 10 percent or more ownership interest in the applicant
 
​Licensed and Certified SURGC/ASC
 
  • Individual direct and indirect owners with five percent or more ownership interest in the applicant entity
  • Officers and directors of applicant and any entity with five percent or more ownership interest in the applicant 

Tips

  • Page 2, section B — The date of birth is an identifier, as several people may have the same name. This will ensure that each individual is associated with the correct facility or entity
  • 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 E; 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

[HSC section 1212]

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

[HSC section 1212]

A resume is required for the Administrator(s)

HS 309 1st Page​ (PDF)


Administrative Organization

[HSC section 1212]

Along with the HS 309, the following supporting documents according to organizational type must be submitted:

Supporting Documents​

Corporation (if applicable)

[HSC section 1212]

  • 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)
  • A copy of the Resolution authorizing the filing of the application
  • A copy of authorization of a foreign (out of state) corporation to do business in California
Tips 
  • Page 1, item 3 — The incorporation date is located in the top right corner of the applicant Articles of Incorporation
  • In addition to this page, corporations are required to complete item 5 on page 2

Supporting Documents​


Limited Liability Company (LLC)

[HSC section 1212]

  • Filing Statement from the Secretary of State
  • Articles of Organization
  • LLC Operating Agreement
  • List of Managing Members (only if additional space is needed to input all managing members)
  • A copy of the Resolution authorizing the filing of the application
  • A copy of authorization of a foreign (out of state) corporation to do business in California
Tips
  • Page 1, item 3 — The incorporation date is located in the top right corner of the Articles of Organization
  • Ensure the operating agreement identifies the Capital Contributions, which lists each individual and/or entity that is contributing to the LLC​

HS 309 2nd Page​ (PDF)


Organizational Structure

Only complete fields that are applicable to applicant’s entity type

Tip

  •  Page 2, item 1 Health care districts will fill in the circle for other
​Supporting Documents

Partnership

[HSC section 1212]

Copy of signed Partnership Agreement

STD 850 (PDF) 

Fire Safety Inspection Request (not applicable for a CHOW) 

[HSC section 1226(f)]​

The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form.



Required Documents for Medi-Cal Certification Only

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, section C, Page 8, item 3.c.1
  • Notarized signature page is required
  • Submit the “Acknowledgement” page from the notary public
​​

Required Documents for Medicare Certification Only

Forms and Supporting Documents​​​

Additional Instructions

(Each form listed also has instructions on the form) ​

CMS 855B (PDF)

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 370 (PDF) 


Health Insurance Benefits Agreement

Submit 2 copies of the CMS 370 form with original signatures

CMS 377 ​(PDF) 

Ambulatory Surgical Center Request for Initial Certification

Submit one copy of the CMS 377 form



Required Documents for a CHOW Only​

Forms and Supporting Documents​​​

Additional Instructions

(Each form listed also has instructions on the form) ​

Supporting Docum​ents

In addition to the forms required for an Initial application listed above submit the documents requested below:

  • ​Copy of Purchase Agreement or Operating Transfer Agreement [HSC section 1212]

  • A letter from the prospective licensee (to CDPH) stating the location where the stored patient medical records will be maintained and affirming the records will be made available to the previous licensee [HSC section 1212 and 123145]


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