HS 200 (02/2008) – Licensure and Certification Application HS 215A (02/2008) – Applicant Individual Information HS 309 (10/2011) – Administrative Organization Enter the center’s license capacity. Room 509F Washington, D.C. 20201. California Department of Public Health Home Health Agency – BRANCH OFFICE ENROLLMENT . Cdph 530. HS 215 A (PDF) - Applicant Individual Information* HS 269 (PDF) - Application for Medi-Cal Certification as a Primary Care Clinic Provider. Fill out, securely sign, print or email your cdph form instantly with SignNow. Application Form Guidance - CDPH Licensing and Certification (L&C) launched several online training videos to provide guidance to providers completing application packets for facility licensing. Cal Health Find provides health care consumers and providers with information about licensed and certified facilities throughout California. All Forms. A.8.a. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. PO Box 997377 Available for PC, iOS and Android. the licensure and certification application form HS 200 is a multi-purpose form used for all facility types that are licensed by the Department of Public Health centralized applications ranch the HS 200 is a four-page form broken up into sections application information licensee information facility agency or clinic information and property information each section is required to be filled out and the information is … 850 18 HHS 690 (05/16) PSC Publishing Services (301) 443-6740. Please turn on JavaScript and try again. Español, - HS 200 Author: CDPH Keywords: HS 200,Licensure & Certification Application,CDPH,Licensing and Certification,internet form Last modified by: Tammy Schmitt Created Date: 3/13/2019 8:17:00 PM Company: State Of Wyoming Other titles: Licensure & Certification Application (1-833-422-4255). PO Box 997377 Box 997416 Sacramento, CA 95899-7416 PHONE: (916) 327-2445 FAX: (916) 552-8785. Sacramento, CA 95899-7377, For General Public Information: Sacramento, CA 95899-7377, For General Public Information: Start a free trial now to save yourself time and money! B.1. Training videos are available for the following forms: Licensure & Certification Application Form (HS 200) Applicant Individual Information (HS 215A) Licensure And Certification Application {HS-200} This is a California form that can be used for Licensing And Certification within Statewide, Department Of Health And Human Services. MS 0500 200 Independence Ave., S.W. Enter the days and hours of operation (business hours) and the hours of service (program hours). Is construction required No If yes submit copy of OSHPD form see instructions on page 6 If yes date construction to begin HS 200 02/08 B. Decrease, Reset We recommend that you obtain a Business License Compliance Package (BLCP)®. MS 0500 Reset Inform CDPH of intent to use mobile sterile compounding unit prior to delivery of the mobile unit by emailing to: LNCPharmCleanRoom@cdph.ca.gov • Submit Form HS 200 to Central Application Unit (CAU) • Hospital to submit Program Flexibility Request (Form 5000) for CCR, Division 5, … CDPH Releases Reports on Healthcare-Associated Infections, Influenza Vaccination Rates Among Healthcare Personnel CDPH Warns Consumers Not to Eat … (916) 558-1784, COVID 19 Information Line: Learn more about how to protect yourself and your family. Hs 200. to Default, Methicillin-Resistant Staphylococcus Aureus Bloodstream Infection, Registered Environmental Health Specialist, Mosquito Disease Surveillance and Control, California Health Facilities Information Database, Chronic Disease Surveillance and Research, Medical Marijuana Identification Card Program, Office of State Public Health Laboratory Director, Centers for Disease Control and Prevention. It looks like your browser does not have JavaScript enabled. The HS 200 can be downloaded from the link listed above. (916) 558-1784, COVID 19 Information Line: 1-833-4CA4ALL HS 200 Application for Facility License HS 215A Applicant Information HS 308 Administrative Responsibility ... HS 609 Bed or Service Request CDPH 241–267 Supplemental Service Applications CDPH 268 Application for Supplemental Services Approval CDPH 709 Client Accommodations Analysis DHCS 9098 Medi-Cal Institutional Providers Agreement Fill out, securely sign, print or email your CDPH 5000 - California Department of Public Health - State of ... - cdph ca instantly with SignNow. For new facilities, complete the column marked "Requested Beds." Please do not enclose the licensure fee, there is no fee. Details: State of California- Health and Human Services Agency California Department of Public Health (CDPH) Licensing and Certification Program (L&C) Aide and Technician Certification Section (ATCS) MS 3301, P.O. In addition to the HS 200 instructions, use the guidance and assistance provided below when completing the form. Name and Title of Authorized Official (please print or type) Name of Agency Receiving/Requesting Funding. U.S. Department of Health & Human Services Office for Civil Rights. If you are evacuated due to wildfires, bring a face covering and hand sanitizer and continue to practice physical distancing when possible to protect against COVID-19. Required Forms for a Branch Office to be Licensed: • Licensure & Certification Application: HS 200 • Medicare General Enrol lment Health Providers/Supplier Application: CMS 855A • Home Health Agency Survey and Deficiencies Report: CMS 1572(a) (b) CDPH HHA Licensing home page: Section: Instruction: A.3 Enter the license fee. Please refer to CDPH website. For existing facilities, complete both columns. Español, - HS 200 (PDF) - Licensure and Certification Application. Fill out, securely sign, print or email your hs200 form instantly with SignNow. *If you are having difficulty accessing any of these documents, please contact CDPH at (916) 558-1784 to request information in an alternate format. This tutorial video guides applicants on how to complete the HS 309 form. (1-833-422-4255). Street Address City, State, Zip Code. Licensure & Certification Application: HS 200 Application Individual Information: HS215A Bed or Service Request: CDPH 609 Application for Outpatient Service: CDPH 246 Application for Supplemental Services Approval: CDPH 268 Client Accommodation Analysis: CDPH 709 Fire Safety Inspection Request: Std.  Please be advised that a fire inspection form (STD 850) must be submitted when an outpatient clinic service is … Read blogs and articles that feature the California Department of Public Health. application for a home care organization license ( ) for department use only reply to: home care organization number: _____ Credit, CDPH 512 (PDF) - License Renewal Affidavit for Nursing Home Administrators, CDPH 513 (PDF) - Licensee's Request for Course Approval, CDPH 514 (PDF) - NHA/Facility Profile Sheet, CDPH 515 (PDF) - Preceptor Continuing Education Credit Application, CDPH 516 (PDF) - NHAP Preceptor Training Registration Form, CDPH 518 (PDF) - Provider Request for Course Approval, CDPH 519 (PDF) - Provider Request for Course Renewal, CDPH 520 (PDF) - Re-Examination Application for Nursing Home Administrator State Examination, CDPH 521 (PDF) - Re-Examination Application for Nursing Home Administrator National Examination, CDPH 522 (PDF) - Request for Provider Renewal, CDPH 523 (PDF) - Special Accommodation Request for Examination, CDPH 524 (PDF) - Master's or Reciprocity Application for Nursing Home Administrator Examination, CDPH 525 (PDF) - Application for Provisional License, CDPH 526 (PDF) - AIT Program Application for Re-Training, CDPH 530 (PDF) - Nursing Staffing Assignment and Sign-In Sheet, CDPH 605 (PDF) - Healthcare Associated Infections (HAI) Advisory Committee Application for Appointment, CDPH 611 (PDF) - Affiliate Primary Care Clinic Application, CDPH 612 (PDF) - Census and Nursing Hours Per Patient Day (NHPPD), CDPH 709 (PDF) - Client Accommodations Analysis, CDPH 929 (PDF) - Request for Name/Address Change and/or Duplicate for CNA/HHA/CHT Certificate, CDPH 931 (PDF) - Verification of Current Nurse Assistant Certification, CDPH 5000 A (PDF) - Temporary Permission for Program Flexibility for Increased Patient Accommodations, HS 200 (PDF) - Licensure and Certification Application, HS 215 A (PDF) - Applicant Individual Information*, HS 269 (PDF) - Application for Medi-Cal Certification as a Primary Care Clinic Provider, HS 309 (PDF) - Administrative Organization and Organizational Structure, HS 328 (PDF) - Notice of Effective Date of Provider Agreement, HS 400 (PDF) - Affidavit Regarding Patient Money, HS 610 (PDF) - Medically Underserved or Health Professional Shortage Areas. Provider or legal representative means the Board Chairperson, President, or Managing Employee. Decrease, Reset to Default, California Conference of Local Health Officers, Communicable Disease Control And Prevention, Chronic Disease Injury Prevention Agenda 1-5-2017, Chronic Disease Injury Prevention Agenda 2-15-2017, Chronic Disease Injury Prevention Agenda 3-2-2017, Center for Chronic Disease Prevention and Health Promotion, Division of Chronic Disease and Injury Control, Tobacco Education and Research Oversight Committee, Preventive Medicine Public Health Residency Program, California Epidemiologic Investigation Service Fellowship Program, California Stroke Registry-California Coverdell Program, Guidelines, Resources, and Evidence-Based Best Practices for Providers, Chronic Disease Surveillance and Research Branch, California Comprehensive Cancer Control Program, California's Comprehensive Cancer Control Plan, Domestic Violence/Intimate Partner Violence, Child Passenger Safety (CPS) In California, Drowning Prevention: Toddler Pool and Spa Safety, Nutrition Education and 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Stem Cell Research Advisory Committee, I&E Program Consultants and Contract Managers, Local Maternal, Child and Adolescent Health, Emergency Preparedness: Infant and Young Child Feeding, Healthy Weight for Healthy Birth and Beyond, Multiple Factors Affect Birthing Parents’ Weight, Regional Perinatal Programs of California, Where We Are: Local RPPC Sites and Coordinators, Resources for Hospital and Health Care Providers, California Maternal Quality Improvement Toolkit, CMQCC Improving Health Care Response to Maternal Venous Thromboembolism, CMQCC Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum, Sudden Infant Death Syndrome (SIDS) Program, Title V Maternal and Child Health Block Grant, MonitoringAdherenceToHCPracticesThatPreventInfection, Healthcare Personnel Influenza Vaccination Reporting In CA Hospitals, CA Campaign To Prevent BSI in Hemodialysis Patients, Central Line-associated Blood Stream Infection (CLABSI), Methicillin-Resistant Staphylococcus 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Quarterly Binational Epidemiology Meetings, Border Infectious Disease Surveillance - Coccidioidomycosis, Border Infectious Disease Surveillance - Queso Fresco, Border Infectious Disease Surveillance - Mosquito-borne-diseases, Border Infetious Disease Surveillance - Rocky Mountain Spotted Fever, Border Infectious Disease Surveillance - Influenza and Other Respiratory Infections, Emergency and Evacuation Planning Guide for Schools, Tips for Communicating with Students During an Emergency, Know When and How to Shelter-in-Place for Schools, How to Help Students Cope and Deal with Stress, Pandemic Flu Preparedness For Schools - Home, Fusion Center (Strategic Development and External Relations), Office of Health Equity - Health Equity Policy & Planning Unit, Climate Change and Health Equity Program (CCHEP), Office of Health Equity Advisory Committee, Health Research and Statistics Unit (HRSU), CDPH Climate Change and Health Profile Reports, CDPH Climate Change and Health Vulnerability 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