Please do not enclose the licensure fee, there is no fee. By Program BCIA 8016 NHAP (PDF) |  Please be advised that a fire inspection form (STD 850) must be submitted when an outpatient clinic service is … PO Box 997377 For new facilities, complete the column marked "Requested Beds." *If you are having difficulty accessing any of these documents, please contact CDPH at (916) 558-1784 to request information in an alternate format. The form is to accompany the application form (HS 200) for any new facility, change in capacity, service, or bed classification. Training videos are available for the following forms: Licensure & Certification Application Form (HS 200) Applicant Individual Information (HS 215A) Reset application for a home care organization license ( ) for department use only reply to: home care organization number: _____ Available for PC, iOS and Android. 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. 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 Decrease, Reset 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. 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 … 1-833-4CA4ALL The HS 200 can be downloaded from the link listed above. (1-833-422-4255). 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. Start a free trial now to save yourself time and money! Age range of clients 10. B.1. 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 … Cdph 530. Please turn on JavaScript and try again. Cal Health Find provides health care consumers and providers with information about licensed and certified facilities throughout California. BCIA 8016 (PDF) | BCIA 8016 Sample (PDF) |  If the licensee, facility, or property information is incorrect because the information has changed, resubmit the L&C Application form (HS 200). Room 509F Washington, D.C. 20201. Street Address City, State, Zip Code. , License & Certification Application Form (HS-200) In all likelihood, the License & Certification Application Form (HS-200) is not the only document you should review as you seek business license compliance in,. Hs 200. To be completed by the California Department of Public Health Proposed name of facility/agency/clinic Enter the name of your facility as it appears on your application (HS 200). This tutorial video guides applicants on how to complete the HS 309 form. HS 215 A (PDF) - Applicant Individual Information* HS 269 (PDF) - Application for Medi-Cal Certification as a Primary Care Clinic Provider. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. PO Box 997377 FY17Q4 Immunizations (pdf) Children With Age Appropriate Immunizations 12-18 Months Old and Active in FCM From 04/01/2017 Through 06/30/2017 Statewide HS 200 (02/2008) – Licensure and Certification Application HS 215A (02/2008) – Applicant Individual Information HS 309 (10/2011) – Administrative Organization (916) 558-1784, COVID 19 Information Line: A.10.a. MS 0500 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. Learn more about how to protect yourself and your family. (916) 558-1784, COVID 19 Information Line: All Forms. 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: It looks like your browser does not have JavaScript enabled. (1-833-422-4255). HHS 690 (05/16) PSC Publishing Services (301) 443-6740. Please turn on JavaScript and try again. We recommend that you obtain a Business License Compliance Package (BLCP)®. This tutorial video guides applicants on how to complete the HS 215A form. This tutorial video guides applicants on how to complete the CDPH 246 form. 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Reset In addition to the HS 200 instructions, use the guidance provided … Section: Instruction: A.3. Forms Access forms used by the Department of Health Care Services. 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. EF "Licensure & Certification Application," HS 200 (2/08), signed by the provider or legal representative. U.S. Department of Health & Human Services Office for Civil Rights. It looks like your browser does not have JavaScript enabled. Sacramento, CA 95899-7377, For General Public Information: For existing facilities, complete both columns. In addition to the HS 200 instructions, use the guidance and assistance provided below when completing the form. californiahealth and human services agency communitycare licensingdivision californiadepartmentof social services homecare services bureau. 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