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.
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:
Licensee physical address
Facility name and address
Facility ID number (if known)
Brief description of request
Previous and proposed/new location
Applicant Contact Information (name, title, phone number, applicant contact email address)
The Department will use the applicant contact email address to send all application correspondence
General Contact Information (name, title, phone number, fax, email address, and alternative contact information)
The Department will use this information to contact the facility for day-to-day business
Emergency Contact Information (name, phone number, fax, email address, alternate email, 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)
All Facility Letter Contact Information (name, phone number, fax, and email address)
The Department will use this information to send All Facility Letters
Facility Contact (Public Use) Information (phone number, fax, email address, and website address)
The Department will use this information to store facility contact information for the public
Privacy Officer Contact Information (name, title, mailing address, phone number, and email address)
The Department will use this information to correspond with the facility's Privacy/Compliance Officer regarding medical breach incidents
Signature
Fire Safety Inspection Request
[Health and Safety Code (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
Control of Property
Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee
(Each form listed also has instructions on the form)
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
Noridian Healthcare Solutions Recommendation of Approval Letter
This letter is issued by Noridian Healthcare Solutions after validation of the CMS 855B Medicare enrollment application
The letter should be included with the application packet
Licensure & Certification Application
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
A.10 – Construction Documents
[HSC section 1226.5]
If construction occurred and if the construction resulted in a new building or addition:
Submit a Certificate of Occupancy
D.1 – Control of Property
Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee.
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
Notarized signature page is required
Submit the “Acknowledgement” page from the notary public, if applicable