Rehabilitation Clinic and Outpatient Physical Therapy/Speech-Language Pathology Providers
Change of Ownership Application Packet

A State license is required to operate a Rehabilitation Clinic (REHABC) in California. A REHABC means "a clinic that, in addition to providing medical services directly, also provides physical rehabilitation services for patients who remain less than 24 hours. Rehabilitation clinics shall provide at least two of the following rehabilitation services: physical therapy, occupational therapy, social, speech pathology, and audiology services. A rehabilitation clinic does not include the offices of a private physician in individual or group practice," pursuant to Health and Safety Code (HSC) section 1204(b)(3). A REHABC may also apply for certification as an Outpatient Physical Therapy and Speech-Language Pathology (OPT/SP) provider. An OPT/SP is a rehabilitation agency that provides an integrated interdisciplinary rehabilitation program designed to upgrade the physical functioning of handicapped disabled individuals by bringing specialized rehabilitation staff together to perform as a team and provides at least physical therapy or speech-language pathology services, pursuant to Title 42 Code of Federal Regulations (CFR) section 485.703. 

To report a Change of Ownership, you must complete the required application packet. Refer to HSC sections 1200 through 1245 for information regarding licensure requirements. Refer to 42 CFR Part 485, Subpart H for the Conditions Of Participation For Outpatient Physical Therapy and Speech-Language Pathology Services.

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. The Sample Application Packet is a visual aid that displays a sample of the completed forms contained in the application packet.

Please refer to the following links to get started:

• Provider Instructions (PDF)
• Provider Checklist (PDF)
• Sample Application Packet (PDF)

Application Packet Forms

Applicants must complete and submit the following forms in the application packet:

• HS 200 – Licensure and Certification Application (PDF)
• CDPH 609 – Bed or Service Request (PDF)
• HS 215A – Applicant Individual Information (PDF)
• HS 309 – Administrative Organization (PDF)
• STD 850 – Fire Safety Inspection Request (PDF)
• HS 328 - Notice-Effective Date of Provider Agreement (PDF)
• CMS 855A - Medicare Enrollment Application (PDF)
• DHCS 6207 - Medi-Cal Disclosure Statement (PDF)
• DHCS 9098 - Medi-CAL Provider Agreement (PDF)
• CMS 1561 - Health Insurance Benefit Agreement (PDF)
• HHS 690 - Assurance of Compliance (PDF)
• CMS 1856 - Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy and/or Speech Pathology Services (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 Program
          Centralized Applications Branch
          P.O. Box 997377, MS 3207
          Sacramento, CA 95899-7377