Skilled Nursing Facility
Change of Certification Application Packet

A State license is required to operate as a Skilled Nursing Facility (SNF) in California. A SNF is “a health facility that provides skilled nursing care and supportive care to patients whose primary need is for availability of skilled nursing care on an extended basis,” pursuant to Health and Safety Code (HSC) section 1250(c). A SNF also means “a health facility or a distinct part of a hospital which provides continuous skilled nursing care and supportive care to patients whose primary need is for availability of skilled nursing care on an extended basis. It provides 24-hour inpatient care and, as a minimum, includes physician, skilled nursing, dietary, pharmaceutical services and an activity program,” pursuant to Title 22 of the California Code of Regulations (CCR) section 72103.

To apply for Medi-Cal and/or Medicare certification for a licensed healthcare facility, you must complete the required application packet.​​

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​
  
• Provider Checklist​ 
  

Application​ Packet Forms

• ​HS 200 - Licensure and Certification Application (PDF, 1.5MB)​​
• CMS 671 - Long Term Care Facility Application for Medicare & Medicaid​ (PDF)​
  
• HS 328 - Notice of Effective Date of Provider Agreement (PDF)
  
• DHCS 9098 - Medi-Cal Provider Agreement (PDF)
• CMS 855A - Medicare Enrollment Application (Institutional Providers)​ (PDF)
• CMS 1561​ - Health Insurance Benefit Agreement​ (PDF)
  
• HHS 690 - Assurance of Compliance​ (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