HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Hospice Facility

Report of Change Application Checklist for Change of Service

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.

Checklist and Instructions - Please submit your documents in this order

Required Documents to Add a Service/Equipment Change

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 Facility name and 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
HS 200 (PDF, 1.5MB)	Licensure & Certification Application (REVISED 7/2023) [Health and Safety Code (HSC) section 1748(b)] Tips: Page 3, section A, item 9 – If the facility, agency, or clinic indicates they operate 24/7/365, complete “b" to indicate the hours of operations for the public. This information is used for surveying purposes. Page 3, section B, item 2 –Provide the EIN of the licensee. Do not enter a Social Security number in this field. Page 6, section B, item 6 — An organization must own 100 percent of the licensee to be considered a parent company. This parent company will have its own Employer Identification Number (EIN)
Supporting Documents	Section A.10 - Health Care Access & Information (HCAI) and/or Certificate of Occupancy (CO) If the facility is newly constructed or a remodeled building, or if this is not a previously licensed facility the facility shall be under the jurisdiction of HCAI or the local building department Hospice Facility located within the physical plant of another facility [HSC 1339.43(e)(1)] Shall be under the jurisdiction of OSHPD Submit HCAI CO, Construction Final (CF) or Substantial Completion (SC) Freestanding Hospice Facility located on the site of or is physically connected to a health facility that is under the jurisdiction of both [HSC 1339.43(f)] Submit new construction or renovation plans to HCAI for review and approval Submit HCAI CO, CF or SC All Other freestanding Hospice Facilities [HSC 1339.43(d)(1) and (2)] Shall be under the jurisdiction of the local building department Submit CO from local building department
Supporting Documents	Section D.1 - Property Information (only required for new property) Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee If the licensee owns the property, submit a signed copy of the Grand Deed, or Bill of Sale If the licensee rent, lease, or sublease, submit the signed copy of the agreement (i.e., rental agreement and/or master lease between the property owner/manager and the perspective licensee)
Supporting Documents	Floor Plan Submit a floor plan that coincides with your office space
STD 850 (PDF)	Fire Safety Inspection Request [HSC section 1339.43(c), (d)(1)] The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form. The OSHPD Fire Life & Safety (FLS) Inspection approval does not replace this form

Medicare Certification Documents

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

CMS 417 (PDF)

Hospice Request for Certification in the Medicare Program

The form requires a signature and date
If this freestanding hospice is “licensed only” the completed form is required to identify the types of services