Intermediate Care Facilities for the Developmentally Disabled
Change of National Provider Identifier Application Packet

A State license is required to operate as an Intermediate Care Facilities for the Developmentally Disabled (ICF/DD) facility in California. An ICF/DD means “a facility that provides 24-hour personal care, habilitation, developmental, and supportive health services to persons with developmental disabilities whose primary need is for developmental services and who have a recurring but intermittent need for skilled nursing services,” pursuant to Health and Safety Code (HSC) section 1250(g).

To report a Change of National Provider Identifier (NPI), you must complete the required application packet. Refer to Title 42 of the Code of Federal Regulations (CFR) 424.506 and CFR 431.107 (b)(5)(i) for information regarding NPI enrollment requirements and furnishing the NPI to the State agency.

How to Apply

An applicant must submit a completed application packet to the Centralized Applications Branch (CAB). The provider instructions are a resource to guide you through the process. The provider checklist identifies the required forms and supporting documents needed to apply for licensing and certification. 

Please refer to the following links to get started:

• Provider Instructions​
  
• Provider Checklist 
  

Applicatio​​n Packet Forms

• ​HS 200 - Licensure and Certification Application (PDF, 1.5MB)​
  
• DHCS 9098 - Medi-Cal Provider Agreement (PDF)

• CMS ​855A - Medicare Gene​ral Enrollment Health Care Provider/Supplier Application (PDF)​​​

Where to Submit Applications

Submit completed application packets to the CAB at the address listed below. Do not send any completed application packets, forms, or supporting documents to the local CDPH, District Office.

          California Department of Public Health
          Licensing and Certification Division
          Centralized Applications Branch
          P.O. Box 997377, MS 3207
          Sacramento, CA 95899-7377