Learn more about how to protect yourself and your family. By Program Fill out, securely sign, print or email your cdph form instantly with SignNow. All Forms. Cdph 5000 Form. 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: Available for PC, iOS and Android. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. Sacramento, CA 95899-7377, For General Public Information: 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. PO Box 997377 If information on the officers or board members is incorrect because the information has changed, resubmit the Administrative Organization form (HS 309). MS 0500 The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. Please turn on JavaScript and try again. A.8.a. 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. Please refer to CDPH website. Section: Instruction: A.3. Provider or legal representative means the Board Chairperson, President, or Managing Employee. 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. A.8.a. Read blogs and articles that feature the California Department of Public Health. B.1. 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. For existing facilities, complete both columns. 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 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