HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Primary Care Clinic - Affiliate

Report of Change Application Checklist for Change of Certification

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.

Medi-Cal
Medicare

Checklist and Instructions - Please submit your documents in this order

Required Documents for a Change of Certification

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

Cover Letter

Letter on company letterhead with the following information:
License number (only applicable for CHOW)
Facility name and address
Facility ID number (if known)
Brief description of request
Attestation that the applicant provider is located in proximity, in time and distance, to a facility with the capacity for management of obstetrical and neonatal emergencies, including the ability to provide cesarean section delivery, within 30 minutes from time of diagnosis of the emergency. Include the facility name and address with the capacity for management of obstetrical and neonatal emergencies

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

[Health and Safety Code (HSC) Section 1212]

Complete the following:

Page 1, Section A

Items: 1, 4, 5, 6, 7

Page 2, 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)

Page 3, Section C

Items 2, 3, 4, 7

Tip:

Page 3, section C, item 7 — When listing the names of individuals with direct or indirect ownership of the facility in section C, provide the EIN (do not enter a Social Security number in this field)

Medi-Cal Certification Documents

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
DHCS 6207 (PDF)	Medi-Cal Disclosure Statement Only complete section V
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, page 3, section C, item 4 Notarized signature page is required Submit the “Acknowledgement” page from the notary public
DHCS 1051 (PDF)	Civil Rights Compliance Review Send directly to Office of Civil Rights – address is on last page of the form
HS 269 (PDF)	Application for Medi-Cal Certification as a PCC Complete, sign and date Tips: A Change of Ownership means the non-profit corporation owning and operating the primary care clinic does not share the same federal tax identification number as the previous number The HS 269 form requires a National Provider Identifier number in lieu of the Medi-Cal provider number Page 1, question 4: The specific type of service, advice, and treatment matches any other document included with your application Page 1, question 5: List Medi-Cal as a source of funds
HS 328 (PDF)	Notice - Effective Date of Provider Agreement If applying for both Medi-Cal & Medicare certification, only submit one copy of this form