Primary Care Clinic - Affiliate Mobile Clinic
Change of Ownership Application Packet

A State license is required to operate a “community” or “free” Primary Care Clinic (PCC) in California, which are defined as:

A community clinic is “a clinic operated by a tax-exempt nonprofit corporation that is supported and maintained in whole or in part by donations, bequests, gifts, grants, government funds or contributions that may be in the form of money goods, or services. In a community clinic, any charges to the patient shall be based on the patient’s ability to pay, utilizing a sliding scale,” pursuant to Health and Safety Code (HSC) section 1204 (a)(1)(A).

A free clinic is “a clinic operated by a tax-exempt nonprofit corporation supported in whole or in part by voluntary donations, bequests, gifts, grants, government funds or contributions that may be in the form of money, goods, or services. In a free clinic there shall be no charges directly to the patient for services rendered or for drugs, medicines, appliances, or apparatuses furnished,” pursuant to HSC section 1204 (a)(1)(B).

A clinic corporation on behalf of a PCC that has held a valid, unrevoked, and unsuspended license for at least the immediately preceding five years, with no demonstrated history of repeated or uncorrected violations or any regulation that pose immediate jeopardy to a patient, and that has no pending action to suspend or revoke its license may file an affiliate clinic application to establish a PCC at an additional site or a mobile health care unit, pursuant to HSC section 1218.1. The clinic corporation (parent clinic) that operates the existing licensed PCC may file an affiliate clinic application if all the following conditions are met:

1. the corporate officers are the same;
2. are owned and operated by the same nonprofit organization with the same board of directors; and,
   
3. have the same medical director or directors and medical policies, procedures, protocols, and standards.
   

Mobile service unit or mobile unit means a special purpose commercial coach or a commercial coach that provides medical, diagnostic, and treatment services and does not mean a modular, relocatable, or transportable unit that is designed to be placed on a foundation when it reaches its destination, nor does it mean any entity that is exempt from licensure, pursuant to HSC section 1765.105.

To report a Change of Ownership, you must complete the required application packet. Refer to HSC sections 1200 through 1245 for licensure requirements. Refer to HSC sections 1765.101 through 1765.175 for information regarding Mobile Health Care Units.

How to Apply

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

Please refer to the following links to get started:

• Provider Instructions (PDF)
• Provider Checklist (PDF)
  

Application Packet Forms

• HS 215A - Applicant Individual Information (PDF)
  
• HS 269 - Application for Medi-Ca Certification as a Primary Care Clinic Provider (PDF) 
  
• CDPH 611 - Licensing and Certification for an Affiliate Primary Care Clinic Application (PDF) 
  
• STD 850 - Fire Safety Inspection Request (PDF)
  
• DHCS 6207 - Medi-Cal Disclosure Statement (PDF)
• DHCS 9098 - Medi-Cal Provider Agreement​ (PDF)
• HS 328 - Notice of Effective Date of Provider Agreement (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