HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Ambulatory Surgery Center

Report of Change Application Checklist for Change of Service

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.

Checklist and Instructions - Please submit your documents in this order

Required Documents for a Change of Service

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: Facility name and address Facility ID number (if known) Brief description of request Include service(s) adding or removing 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
HS 200 (PDF, 1.5MB)	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 Note: Not applicable to Medicare providers
Supporting Documents	A.10 – Certificate of Occupancy [24 CCR section Part 2 section III] [Title 42 Code of Federal Regulations (CFR) section 416.44] If construction occurred and if the construction resulted in a new building or addition: Submit a Certificate of Occupancy
STD 850 (PDF)	Fire Safety Inspection Request [Health and Safety Code (HSC) section 1226(f)] [24 CCR Part 9 section 1.1.3.1] If construction occurred: 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

Medicare Certification Documents

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
Supporting Documents	Noridian Healthcare Solutions Recommendation of Approval Letter This letter is issued by Noridian Healthcare Solutions The letter should be included with the application packet
CMS 377 (PDF)	Ambulatory Surgical Center Request for Initial Certification Submit one copy of the CMS 377 form

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