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
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 to add Medicare [Title 18] and/or Medi-Cal [Title 19]
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
Long Term Care Facility Application for Medicare and Medicaid
Original signature required on this form
Licensure & Certification Application
[Health and Safety Code (HSC) Section 1212]
Page 3, 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 7, Section C
Tip:
Page 9, Section 5 - 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 on the HS-200 form)
Page 17, Attachment F–1
Notice - Effective Date of Provider Agreement
If applying for both Medi-Cal & Medicare certification, only submit one copy of this form
Additional Instructions
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
Health Insurance Benefit Agreement
Submit two (2) signed copies:
Sign the bottom signature block entitled “Accepted for the Successor Provider of Services By”
Assurance of Compliance
Office of Civil Rights requires the HHS 690 form be submitted.