HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Hospice Agency

Report of Change Application Checklist for Change of Geographical Service Area

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 Change Geographical Service Area

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 Previous and proposed/new location 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)
CMS 855A (Page 23 Only) (PDF)	Geographic Service Area Submit a list of the geographical areas (including cities, counties, and zip codes) to be served Submit a web-based map Hospice agencies must obtain prior approval of an expansion of their geographic service area from the Centers for Medicare and Medicaid Services (CMS) and the California Department of Public Health, Licensing & Certification Program

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