HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Hospice Agency

Initial and Change of Ownership Application Checklist

Effective January 1, 2022, Senate Bill (SB) 664 institutes a moratorium on new hospice license. During the moratorium, CDPH will be prohibited from issuing a new license pursuant to Health and Safety Code (HSC) section 1751.70. However, according to HSC section 1751.75, CDPH may grant an exception to the moratorium.

STEP 1: Individuals or entities interested in applying for hospice licensure must begin by submitting an exception request. This consist of submitting a written justification and supporting documentation to demonstrate need based on geographic concentration to the Centralized Applications Branch (CAB). If CAB determines there is a need based on geographic concentration, CAB will notify the applicant they may apply for licensure. Do not submit the required documents listed in the table below for licensure prior to submitting an exception request and receiving CAB determination.

STOP HERE: If you have submitted an exception request, and CAB denied your request you are denied submitting an application. Do not submit an application seeking hospice licensure. Pursuant to SB 664 and HSC 1751.70, CDPH cannot issue you a license to operate a hospice.

For additional information, please refer to AFL 21-53 (https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-21-53.aspx) located on the CDPH website.

STEP 2: If you received notice from CAB that your exception request was accepted, you may submit an application to CAB with a copy of your acceptance letter. 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.

Initial License
Change of Ownership (CHOW)
Medicare
Medi-Cal

Checklist and Instructions - Please submit your documents in this order

Required Documents for an Initial License or CHOW

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 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
SB 664 Supporting Document	Attach a copy of your SB 664 – hospice moratorium acceptance letter received from CAB. Ensure the business address reflects the application package entirely. Your application will automatically be denied if the business address on the licensure application packet is different or inconsistent to the business address on SB 664 – hospice moratorium acceptance letter.
HS 200 (PDF, 1.5MB)	Licensure & Certification Application (Revised 07/2023) [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	IRS – Internal Revenue Service Documentation Submit one of the following IRS tax documents showing entity’s legal name and Tax Identification Number: Form 941- Employer’s Quarterly Federal Tax Return Form 8109- C FTD Address Change Letter 147-C- EIN Confirmation Notification Form SS-4- Confirmation Notification
Supporting Documents	B.3 - Organizational Chart Submit an organizational chart if the type of entity, identified on the HS 200 is a for profit corporation, general partnership, limited liability company (LLC), limited liability partnership, limited partnership, or non-profit. The organizational chart needs to display the following: Applicant’s owners, including ownership percentages, Tax IDs/EINs and all directors, board members, corporate officers, LLC members/managers, and/or partners If the licensee is a subsidiary of another organization Licensee identified in Section B.1, submit an organizational chart to display the relationship Parent company of applicant, if applicable, and all of the licensed agencies/facilities it is operating - see B.6 Note: Submit the HS 215A form for each of these individuals
HS 200 (PDF, 1.5MB)	Section C.1 – Management Agreements Item B: Hospice has no authority to allow management companies. The SNF management companies' authority cannot be used for a hospice. Additionally, interim management agreements between the proposed owner and the current owner cannot be accepted for hospice applicants.
Supporting Documents	Section D – Property Information 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 Grant 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
Supporting Documents	Section F.1 - Subcontractor Information and Significant Business Transactions If the current or proposed agency is applying for Medi-Cal certification, complete and submit the Attachment F-1: Subcontractor Information and Significant Business Transactions. Note: The attachment F-1 document replaces the DHCS 6207 Medi-Cal Disclosure Statement entirely.
HS 215A (PDF)	Applicant Individual Information [HSC section1748(b); Standards of Quality Hospice Care (SQHC, 2003, section 5.1 - 5.3, and 6.1]. This form must be completed for the following individuals and include original signatures: Administrator, Administrator Designee, Director of Patient Care Services, Director of Patient Care Services Designee, and Medical Director or contracted Medical Director Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization Each individual having a beneficial interest of five percent or more in the applicant organization and/or parent organization Tips: Page 2, section B, item 3 – The date of birth is an identifier, as several people may have the same name. This will ensure each individual is associated with the correct facility or entity Page 2, section B, item 4 – Provide your Driver’s License Number or a State-Issued identification Card Number. Attached a copy of the Driver’s License or State-Issued Identification Card for verification. Page 2, section B, item 5 – The Social Security Number is an identifier, as several people may have the same name. this will ensure each individual is associated with the correct facility or entity Page 3, section B, item 7 – Administrator must list the number of hours spent at each agency per week. Page 5, section E – Submit ten years of employment history, indicating the start and end dates of employment, job title, employer name and address. The applicant may submit a resume in lieu of completing section D; however, the resume must contain all required information requested in section E
HS 215A (PDF)	Section H – Facility Information Sheet Each individual must complete and submit the Facility Information Sheet for each facility and/or agency with which the individual has a current or past relationship within the last three years. This sheet must also include any facilities licensed by the California Department of Social Services. The following must be completed for each facility and/or agency: Facility name Facility address Type of facility Type of business entity (include EIN Number) Individual’s nature of involvement Individual’s dates of involvement
Supporting Documents	Resume A resume is required for the Administrator, Administrator Designee, Director of Patient Care Services, Director of Patient Care Services Designee, and Medical Director or contracted Medical Director.
HS 309 1st Page (PDF)	Administrative Organization Along with the HS 309, the following supporting documents according to organizational type must be submitted:
Supporting Documents	For-Profit or Non-Profit Corporation Filing Statement from the Secretary of State Articles of Incorporation By-Laws List of Board of Directors (only if additional space is needed to input all board of directors) Tip: Page 1, item 3 — The incorporation date located in the top right corner of the applicant Articles of Incorporation
Supporting Documents	Limited Liability Company (LLC) Filing Statement from the Secretary of State Articles of Organization Operating Agreement List of Managing Members (only if additional space is needed to input all managing members)
HS 309 2nd Page (PDF)	Organizational Structure Only complete fields that are applicable to applicant’s entity type
Supporting Documents	Public Agency Copy of signed Resolution
Supporting Documents	Limited Liability, Limited, or General Partnership Copy of signed Partnership Agreement
CMS 855A Page 23 (PDF)	Geographical Service Area Submit a list of the geographical areas (including cities, counties, and zip codes) to be served Submit a web-based map Hospice providers 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 (CDPH) Licensing & Certification Program

Required Documents for a CHOW Only

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

Supporting Documents

In addition to the forms required for an Initial application listed above submit the documents requested below:

Copy of Purchase Agreement or Operating Transfer Agreement
A letter from the prospective licensee (to CDPH) stating the location where the stored patient medical records will be maintained and affirming the records will be made available to the previous licensee [SQHC, 2003, Section 6.3 (B)(3)(g)]

Medi-Cal Certification Documents

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

DHCS 9098 (PDF)

Medi-Cal Provider Agreement

Do not leave any questions blank. Enter “same” or “N/A” if not applicable
The mailing address must be the same as reported on the HS 200 form
Notarized signature page is required
Submit the “Acknowledgement” page from the notary public, if applicable

HS 328 (PDF)

Notice - Effective Date of Provider Agreement

If applying for both Medi-Cal and Medicare certification, only submit one copy of 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 [HSC section 1749(b)(1) – (b)(7);SQHC, 2003, section 2.1] The form requires an original signature and date If this freestanding hospice is “licensed only,” complete this form to identify the types of services
CMS 643 (PDF)	Hospice Survey and Deficiencies Report Fill out the Name of Facility only Submit both pages
CMS 855A (PDF)	Medicare General Enrollment Health Care Provider/Supplier Application This application is from the Federal Department of Health and Human Services The completed application should be mailed directly to the appropriate fiscal intermediary
CMS 1561 (PDF)	Health Insurance Benefits Agreement Submit two (2) signed copies with “original” signatures: Initial Application: Sign the top signature block entitled “Accepted for the Provider of Services By” CHOW: Sign the bottom signature block entitled “Accepted for the Successor Provider of Services By”
HHS 690 (PDF)	Assurance of Compliance The Office of Civil Rights (OCR) online portal is: Office for Civil Rights (https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf) Once the online submission is completed, an electronic notification from OCR stating the Assurance of Compliance form was submitted successfully will be received by the applicant Submit a copy of this notification