Rural Health Clinic
Initial 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 of this subpart,” pursuant to Title 42 Code of Federal Regulations (CFR) section 491.2.

Applicants seeking certification as an RHC must be located in a non-urbanized area and in a medically underserved area (MUA) or health professional shortage area (HPSA). The Centralized Application Branch (CAB) makes a preliminary assessment based on the information contained in the application packet. The Centers for Medicare and Medicaid Services (CMS) makes the final determination whether the location qualifies and meets all applicable Federal requirements. 

General Medicare Process Reminder 

Providers seeking Medicare certification must first complete and submit an enrollment application through the Centers for Medicare and Medicaid Services (CMS), prior to submitting a RHC application packet to the Centralized Applications Branch (CAB). Information on Medicare enrollment, applicable forms, and instructions can be found on the CMS website (https://www.cms.gov/medicare/provider-enrollment-and-certification). If you receive a recommendation of approval letter from the Medicare Administrative Contractor (MAC) for California, Noridian Healthcare Solutions, please include a copy of this letter along with your RHC application packet to CAB. ​

To apply for Initial certification, you must complete the required application packet. Refer to 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 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 certification. 

Please refer to the following links to get started:

• Provider Instructions ​
  
• 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)
  
• HS 610 - Medically Underserved or Health Professional Shortage Areas (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 Division
          Centralized Applications Branch
          P.O. Box 997377, MS 3207
          Sacramento, CA 95899-7377​