The following is a list of application forms and supporting documents required for a complete application packet. Failure to include each of the forms and documents will delay processing.
Forms and Supporting Documents
Additional Instructions
(Each form listed also has instructions on the form)
Cover Letter
Cover Letter
Letter on company letterhead with the following information:
License number (only applicable for CHOW)
Facility name and address
Facility ID number (if known)
Brief description of request
Applicant Contact Information (name, title, phone number, invoice contact email address, applicant contact email address)
The Department will use the invoice contact email address to invoice the application fee
The Department will use the applicant contact email address to send all application correspondence
General Contact Information (name, title, phone number, fax, email address, and alternative contact information)
The Department will use this information to contact the facility for day-to-day business
Emergency Contact Information (name, phone number, fax, email address, alternate email, and phone number that will receive text messages)
The Department will use this information to contact the provider in the event of an emergency using the California Health Alert Network (CAHAN). All information provided must allow CAHAN to contact the provider on a 24/7/365 basis for distribution of health alerts.For additional information: CAHAN (https://www.calhospitalprepare.org/cahan)
All Facility Letter Contact Information (name, phone number, fax, and email address)
The Department will use this information to send All Facility Letters
Facility Contact (Public Use) Information (phone number, fax, email address, and website address)
The Department will use this information to store facility contact information for the public
Privacy Officer Contact Information (name, title, mailing address, phone number, and email address)
The Department will use this information to correspond with the facility's Privacy/Compliance Officer regarding medical breach incidents
Signature
Licensure & Certification Application
[Health and Safety Code (HSC) Section 1212]
Complete the following:
Page 1, Section A
Items 1, 3, 4, 5, 6
Page 3, Section B
Items 1, 2, 3, 4
Item 2 supporting document: IRS Tax ID Verification
Page 7, Section C
Items 3, 5
Page 11, Section D
Items 1, 2
Page 12, Section G
Signature(s)
Tip:
Page 9, Section 5 - When listing the names of individuals with direct or indirect ownership of the facility in section C, provide the EIN (do not enter a Social Security number on the HS-200 form)
Page 17, Attachment F–1
Medi-Cal Provider Agreement
Do not leave any questions blank. Enter “N/A” if not applicable
Pages 2-13 must be submitted. Do not omit any of those pages from submission
The mailing address must be the same as reported on the HS 200 form, page 3, section C, item 4
Complete the zip code fields with nine digits for all addresses
Notarized signature page is required
If out of state, notary public seal/stamp should be entered in the space provided on page 12, item 5
Submit the “Acknowledgement” page from the notary public if the notary is from California
Notice - Effective Date of Provider Agreement
If applying for both Medi-Cal & Medicare certification, only submit one copy of this form
CMS 417 (PDF)
Hospice Request for Certification in Medicare
[HSC section 1749(b)(1) - (b)(7); SQHC, 2003, section 2.1]
The form requires a signature and date
If this freestanding hospice is “licensed only,” complete this form to identify the types of services
Hospice Survey & Deficiency Report
Fill out the name of facility only
Submit both pages
Medicare Enrollment Application (Institutional Providers)
This application is from the Federal Department of Health and Human Services
The completed application should be mailed directly to the appropriate fiscal intermediary
Health Insurance Benefit Agreement
Submit two (2) signed copies:
Sign the bottom signature block entitled “Accepted for the Successor Provider of Services By”
Assurance of Compliance
OCR's online portal is: Office for Civil Rights (https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf)
Once the on-line submission is completed, an electronic notification from OCR stating the “Assurance of Compliance form was submitted successfully” will be sent to the applicant
Submit a copy of this notification