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HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Outpatient Physical Therapy/Speech-Language Pathology Provider

Report of Change Application Checklist for Change of Name

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 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

  • Previous and proposed/new name

  • Applicant Contact Information (name, title, phone number, applicant contact email address)

    • 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

[Title 42 Code of Federal Regulations (CFR) section 485.709]

Tip:

  • Attachment F-1 — If the current or proposed facility, agency, or clinic is applying for Medi-Cal certification, complete Attachment F-1: Subcontractor Information and Significant Business Transactions
HS 309 1st Page (PDF)​

Administrative Organization

[42 CFR section 485.709(a)]

  • Corporations complete page one

  • Do no​​t submit any attachments
HS 309 2nd Page (PDF)

Organizational Structure

Only complete fields that are applicable to applicant’s entity type

Tip:

  • Page 2, item 1 — Health care districts will fill in the circle for other

Medi-Cal Certification Documents 

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)​
DHCS 90​98​ (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, section C, Page 3, item 4

  • Notarized signature page is required

  • Submit the “Acknowledgement” page from the notary public


Medicare Certification Documents 

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)
CMS 1856 (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
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

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