Intermediate Care Facility/Developmentally Disabled
&
Intermediate Care Facility/Developmentally Disabled-Habilitative
Report of Change Application Checklist for Change of Name
The following is a list of forms and supporting documents required for a complete application packet. Failure to include every form or document will delay processing or lead to denial.
Checklist and Instructions - Please submit your documents in this order and save a copy of all submitted documents for your records.
Required Documents for a Change of Name
|
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 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) General Contact Information (name, title, phone number, fax, email address, and alternative contact information) Emergency Contact Information (name, phone number, fax, email address, alternate email, and phone number that will receive text messages) All Facility Letter Contact Information (name, phone number, fax, and email address) Facility Contact (Public Use) Information (phone number, fax, email address, and website address) Privacy Officer Contact Information (name, title, mailing address, phone number, and email address)
|
HS 200 (PDF, 1.5MB)
|
Licensure & Certification Application
ICF/DD: Title 22 California Code of Regulations (CCR) section 76225(d)
ICF/DD-H: 22 CCR section 76844(b)(4) and Health and Safety Code (HSC) 1265
Tip:
Page 1, section A, items 3(k) and 3(p) –– Indicate if the change of the name is for the Licensee and/or the Facility
Page 6, section B, item 6 — An organization will have its own Federal tax ID number
Signature must be from the applicant (Licensee/owner), not the Administrator, unless the owner is the Administrator.
|
Supporting Documents
|
Board Resolution
ICF/DD: [22 CCR section 76205(a)(11)]
ICF/DD-H: [HSC section 1265(i)]
Submit a copy of board resolution signed by officers and directors authorizing the facility name change and with the effective date.
|
|
Supporting Documents
|
Articles of Incorporation
ICF/DD: [22 CCR section 76205(a)(2)]
ICF/DD-H: [HSC section 1265(i)]
If the Licensee name or Corporate name changes, submit a copy of amended Articles of Incorporation filed with the CA Secretary of State
Note: In case of entity conversion, submit a copy of conversion document (PDF)(https://bpd.cdn.sos.ca.gov/be/forms/conversion-information.pdf) filed with the CA Secretary of State
|
Medi-Cal Certification Documents
Forms and supporting documents
|
Additional
Instructions
(Each
form
listed
also
has
instructions
on
the
form)
|
DHCS 9098 (PDF, 2.9MB)
|
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
|
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 This document does not go to CAB
|