HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Surgical Clinic/Ambulatory Surgery Center

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, 3, 4, 5, 6

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

Items 3 and 5

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

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, page 3, section C, 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 370 (PDF)	Health Insurance Benefit Agreement Submit two (2) signed copies
CMS 377 (PDF)	ASC Request for Initial Certification or Update for Certification Information Complete, sign, and date
CMS 855A (PDF)	Medicare Enrollment Application (Institutional Providers) This application is from the Federal Department of Health and Human Services The completed application should be mailed directly to the appropriate fiscal intermediary
EIN Verification	EIN IRS Verification Letter: Submit one of the following letters: 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)
HHS 690 (PDF)	Assurance of Compliance Office of Civil Rights requires the HHS 690 form be submitted. Receive confirmation of online submission: U.S. Department of Health and Human Services (https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf)