Rural Health Clinic
Change of Ownership Application Packet

A clinic may be certified as a Rural Health Clinic (RHC) in California. An RHC is “a clinic that is located in a rural area designated as a shortage area, is not a rehabilitation agency or a facility primarily for the care and treatment of mental diseases, and meets all other requirements,” pursuant to Title 42 Code of Federal Regulations (CFR) section 491.2.

To report a Change of Ownership, you must complete the required application packet. Refer to 42 CFR Part 491 Subpart A – Rural Health Clinics for information regarding conditions of certification.

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. 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 ​
  

Application Packet Forms

• ​​​HS 200 - Licensure and Certification Application​ (PDF, 1.5MB)
• HS 215A - Applicant Individual Information (PDF)
• HS 309 - Administrative Organization and Organizational Structure​ (PDF)
• DHCS 9098 - Medi-Cal Provider Agreement​ (PDF)
• HS 328 - Notice of Effective Date of Provider Agreement​ (PDF)
• HHS 690 - Assurance of Compliance (PDF) 
• CMS 29 - Verification of Clinic Data – Rural Health Clinic Program​ (PDF) 
• CMS 1561A - Health Insurance Benefit Agreement – Rural Health Clinic​​ (PDF)
• CMS 855B - Medicare General Enrollment Health Care Provider/ Supplier Application​ (PDF) ​

Where to Submit Application

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