Form HS 200, Licensure & Certification Application Instructions

Check this box if additional sheets containing Subcontractor Information and Significant Business Transactions for Part A are attached. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Check this box if additional sheets containing Subcontractor Information and Significant Business Transactions for Part B are attached. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Enter the full name of the administrator.

Enter the administrator's professional license number.

Enter the expiration date of the administrator's professional license.

Enter the date the administrator was hired.

Enter the age range of clients served by the facility (for example "0-17", "18-64", "65+" or a custom range like "3-21").

Provide the full name of the agency manager.

Enter the professional license number of the agency manager.

Provide the expiration date of the agency manager's professional license.

Enter the date when the agency manager was hired.

Check this box if an additional sheet is attached providing subcontractor information for Part C of the F-1 attachment.

Check this box if an additional sheet is attached providing subcontractor information for Part D of the F-1 attachment.

Enter the facility’s current total number of licensed or staffed beds.

Enter the proposed total number of beds the facility plans to have after any changes or expansion.

Check this box if the Licensee has had any significant business transaction with any wholly owned supplier or subcontractor (not listed on Part A of the F-1 attachment) during the 5-year period immediately preceding the date of this Application.

Check this box if the Licensee has NOT had any significant business transaction with any wholly owned supplier or subcontractor (not listed on Part A of the F-1 attachment) during the 5-year period immediately preceding the date of this Application.

Enter the actual date on which you took charge of the financial management of the facility for the change of ownership for certification purposes. Fill only if 'd. Change of Ownership (see #2 below)' is 'Yes'.

Check this box if the Licensee has been suspended from a Medicare, Medicaid, or Medi-Cal program.

Check this box if the Licensee has not been suspended from a Medicare, Medicaid, or Medi-Cal program.

Check this box if there are Congregate Living Health Facilities (CLHF) within 1,000 feet of this facility.

Check this box if there are no Congregate Living Health Facilities (CLHF) within 1,000 feet of this facility.

Check this box if you do not know whether there are Congregate Living Health Facilities (CLHF) within 1,000 feet of this facility.

Enter the date when construction began for the selected application type.

Enter the date when construction was completed for the selected application type.

Provide the full name of the contact person, including their last, first, and middle names.

Enter the professional title or position of the contact person.

Provide the email address of the contact person.

Enter the telephone number of the contact person.

Provide the telephone number for the current facility.

Provide the email address for the current facility.

Provide the fax number for the current facility.

Enter the full name of the current facility, agency, or clinic.

Please provide the street number and name for the current mailing address of the facility, agency, or clinic.

Please provide the city for the current mailing address of the facility, agency, or clinic.

Please provide the state for the current mailing address of the facility, agency, or clinic.

Please provide the 9-digit zip code for the current mailing address of the facility, agency, or clinic.

Enter the telephone number for the current mailing address of the facility, agency, or clinic.

Enter the street number and name for the current physical address of the facility, agency, or clinic.

Enter the city for the current physical address of the facility, agency, or clinic.

Enter the state for the current physical address of the facility, agency, or clinic.

Enter the nine-digit zip code for the current physical address of the facility, agency, or clinic.

Check this box if the facility, agency, or clinic is in operation 24 hours a day, 7 days a week, 365 days a year.

Enter the hours of operation for Sunday.

Enter the hours of operation for Monday.

Enter the hours of operation for Tuesday.

Enter the hours of operation for Wednesday.

Enter the hours of operation for Thursday.

Enter the hours of operation for Friday.

Enter the hours of operation for Saturday.

Provide a list of service hours if they differ from the standard hours of operation specified in the table above.

Check this box if construction was required for the application type(s) selected.

Check this box if construction was not required for the application type(s) selected.

Enter the full name of the Director of Nursing.

Enter the professional license number for the Director of Nursing.

Enter the expiration date of the Director of Nursing's professional license.

Enter the date the Director of Nursing was hired.

Enter the full name of the Director of Patient Care Services.

Enter the professional license number for the Director of Patient Care Services.

Enter the expiration date of the professional license for the Director of Patient Care Services.

Enter the date the Director of Patient Care Services was hired.

Check this box if there are ICF/DD, ICF/DD-H, ICF/DD-N, Residential Care Facility (RCF), or Pediatric Day Health & Respite Care (PDHRC) facilities within 300 feet of this facility.

Check this box if there are no ICF/DD, ICF/DD-H, ICF/DD-N, Residential Care Facility (RCF), or Pediatric Day Health & Respite Care (PDHRC) facilities within 300 feet of this facility.

Check this box if you do not know if there are ICF/DD, ICF/DD-H, ICF/DD-N, Residential Care Facility (RCF), or Pediatric Day Health & Respite Care (PDHRC) facilities within 300 feet of this facility.

Enter the full name of the facility.

Provide the type of facility.

Enter the street number and street name of the facility's address.

Enter the city of the facility's address.

Enter the state of the facility's address.

Enter the 9-digit zip code of the facility's address.

Check this box if the facility is currently participating in the Medi-Cal program.

Check this box if the facility is not currently participating in the Medi-Cal program.

Check this box if section 4b, regarding license revocation or disciplinary action for the facility, does not apply.

Check this box if the Licensee currently participates or has ever participated as a provider in the Medi-Cal program or another state's Medicaid program.

Check this box if the Licensee does not currently participate and has never participated as a provider in the Medi-Cal program or another state's Medicaid program.

Check this box if section 5b, regarding a final Medi-Cal decertification action for the facility, does not apply.

Check this box if section 5c, regarding fines/debts due to government for health care programs, does not apply.

Enter the name of the facility to be managed.

Enter the Employer Identification Number (EIN) for the facility to be managed.

Enter the street number and name for the facility's address.

Enter the city for the facility's address.

Enter the state for the facility's address.

Enter the 9-digit zip code for the facility's address.

Enter the facility's license number.

Check this box if the facility operates as a Community Mental Health Center (CMHC).

Check this box if the facility is a Comprehensive Outpatient Rehabilitation Facility (CORF).

Check this box if the facility is a Congregate Living Health Facility (CLHF).

Check this box if the facility is a Correctional Treatment Center (CTC).

Check this box if the facility provides End Stage Renal Dialysis (ESRD) services.

Check this box if the facility is a Free Clinic (FREEC).

Check this box if the facility is a Free Clinic or Rural Health Clinic (FREEC/RHC).

Check this box if the facility is a General Acute Care Hospital (GACH).

Check this box if the facility is a Home Health Agency (HHA).

Check this box if the facility is a Hospice Agency.

Check this box if the facility is a Hospice Facility (HOFA).

Check this box if the facility is an Intermediate Care Facility (ICF).

Check this box if the facility is an Intermediate Care Facility for the Developmentally Disabled (ICF/DD).

Check this box if the facility is an Intermediate Care Facility for the Developmentally Disabled - Habilitative (ICF/DD-H).

Check this box if the facility is an Intermediate Care Facility for the Developmentally Disabled - Nursing (ICF/DD-N).

Check this box if the facility provides Outpatient Physical Therapy or Speech-Language Pathology services (OPT/SP).

Check this box if the facility is a Pediatric Day Health and Respite Care provider (PDHRC).

Check this box if the facility is a Psychology Clinic (PSYCHC).

Check this box if the facility is a Referral Agency (REFRLAG).

Check this box if the facility is a Rehabilitation Clinic (REHABC).

Check this box if the facility is a Rehabilitation Clinic or Comprehensive Outpatient Rehabilitation Facility (REHABC/CORF).

Check this box if the facility is a Rural Health Clinic (RHC).

Check this box if the facility is a Skilled Nursing Facility (SNF).

Check this box if the facility is a Surgical Clinic (SURGC).

Check this box if the facility is a Surgical Clinic or Ambulatory Surgery Center (SURGC/ASC).

Check this box if the facility type is not listed above and should be specified as Other.

Enter the name of the facility type if it is not listed among the options above (provide a brief, descriptive label for the other facility type). Fill only if 'ii. Other' is 'Yes'.

Enter the Federal Tax Identification Number or Employer Identification Number (EIN).

Provide the name of the first facility.

Provide the type of the first facility.

Provide the street number and name for the first facility's address.

Provide the city for the first facility's address.

Provide the state for the first facility's address.

Provide the 9-digit zip code for the first facility's address.

Check this box if the facility is participating in the Medi-Cal program.

Check this box if the first facility listed is not participating in the Medi-Cal program.

Enter the full name of the first facility, agency, or clinic.

Provide the street number and street name for the first facility's address.

Enter the city of the first facility's address.

Enter the state of the first facility's address.

Enter the 9-digit zip code for the first facility's address.

Provide the dates during which there was involvement with the first facility, agency, or clinic.

Enter the details or identifier for the first fine or debt.

Enter the name of the agency to which the first fine or debt is owed.

Enter the date the first fine or debt was issued.

Enter the date by which the first fine or debt must be paid in full.

Enter the full name of the first individual with an ownership interest.

Enter the ownership percentage for the first individual.

Enter the specific relationship if the first individual is related to another listed person as a spouse, parent, child, or sibling.

Enter the full name of the first individual.

Enter the ownership percentage of the first individual.

Enter the street number and name for the first individual's address.

Enter the city for the first individual's address.

Enter the state for the first individual's address.

Enter the 9-digit zip code for the first individual's address.

Enter the printed name of the first person signing this declaration.

Enter the date the first person signed this declaration.

Enter the full legal name of the person or entity with 5 percent or more ownership or control interest in the subcontractor.

Enter the phone number for the first owner or controller.

Enter the street number and name for the first owner or controller's address.

Enter the city for the first owner or controller's address.

Enter the state for the first owner or controller's address.

Enter the 9-digit zip code for the first owner or controller's address.

Provide the full legal name of the person or entity with 5 percent or more ownership or control interest in the first subcontractor.

Enter the phone number for the first subcontractor.

Provide the street number and name for the first subcontractor's address.

Enter the city for the first subcontractor's address.

Enter the state for the first subcontractor's address.

Provide the 9-digit ZIP code for the first subcontractor's address.

Provide the full legal name of the first subsidiary organization.

Enter the federal tax identification number for the first subsidiary organization.

Provide the street number and name for the first subsidiary organization's address.

Enter the city for the first subsidiary organization's address.

Provide the state for the first subsidiary organization's address.

Enter the 9-digit zip code for the first subsidiary organization's address.

Provide the National Provider Identifier (NPI) and/or Provider Number(s) for the first suspension program.

Enter the effective date of the first suspension.

Enter the date of reinstatement for the first suspension, if applicable.

Enter the district identifier (name or code) under which this facility will be filed with the department.

Enter the department-assigned ELMS facility number for this location.

Enter the proposed official name of the facility, agency, or clinic exactly as it should appear on department records.

Button to print the entire form. Click this button to generate a printable version of the form.

Button to reset all fields in the form. Click this button to clear all entered data and start over.

Sign here if you have the authority to legally bind the licensee.

Sign here if you have the authority to legally bind the licensee.

Sign here if you have the authority to legally bind the licensee.

Sign here if you have the authority to legally bind the licensee.

Enter the name of the fourth facility, agency, or clinic.

Enter the street number and name of the fourth facility's address.

Enter the city of the fourth facility's address.

Enter the state of the fourth facility's address.

Enter the 9-digit zip code of the fourth facility's address.

Enter the dates of involvement with the fourth facility.

Enter the full name of the fourth individual with ownership interest.

Enter the ownership percentage for the fourth individual.

Enter the relationship if the fourth individual is related to another owner (e.g., spouse, parent, child, or sibling).

Enter the printed name of the fourth person signing the declaration.

Enter the date of the fourth signatory's declaration.

Enter the full legal name of the fourth person or entity with 5 percent or more direct or indirect ownership or control interest in the subcontractor.

Provide the phone number for the fourth person or entity listed.

Enter the street number and name for the fourth person or entity's address.

Enter the city for the fourth person or entity's address.

Enter the state for the fourth person or entity's address.

Enter the 9-digit zip code for the fourth person or entity's address.

Enter the full name of the individual.

Enter the percentage of ownership held by the individual.

Enter the street number and street name of the individual's address.

Enter the city of the individual's address.

Enter the state of the individual's address.

Enter the 9-digit ZIP code for the individual's address.

Enter the individual's ownership percentage if they are a 5 percent or greater owner.

Enter the individual's title if they are a Director or Officer.

Enter a description of the individual's role if it is not listed as an owner, partner, managing employee, director, or officer.

Enter the ownership percentage for the first owner or greater owner.

Enter the title of the first owner/controller if they are a Director or Officer.

Specify the role of the first owner/controller if it is not one of the listed options.

Check this box if there is an interim management agreement between the proposed owner and the current owner to run the facility until the change of ownership is completed.

Check this box if there is no interim management agreement between the proposed owner and the current owner.

Please enter the full name of the lessee, who is the party paying the lessor for the use of the property.

Please provide the street number and street name of the lessee's address.

Please enter the city of the lessee's address.

Please enter the state of the lessee's address.

Please provide the 9-digit zip code for the lessee's address.

Provide the full name of the lessor.

Enter the street number and street name for the lessor's address.

Enter the city for the lessor's address.

Enter the state for the lessor's address.

Enter the 9-digit zip code for the lessor's address.

Provide the email address of the lessor.

Indicate the term or duration of the lease agreement.

Enter the primary phone number for the licensee.

Enter the fax number for the licensee.

Enter the primary email address for the licensee.

Enter an alternate email address for the licensee, if applicable.

Enter the website address for the licensee, if applicable.

Enter the legal name of the licensee as it was reported to the IRS.

Enter the legal name of the licensee as it was filed with the California Secretary of State, if different from the name reported to the IRS.

Enter the street number and name for the licensee's mailing address.

Enter the city for the licensee's mailing address.

Enter the state for the licensee's mailing address.

Enter the 9-digit zip code for the licensee's mailing address.

Enter the full legal name of the management company.

Enter the Employer Identification Number (EIN) for the management company.

Provide the street number and name of the management company's address.

Enter the city of the management company's address.

Enter the state of the management company's address.

Enter the 9-digit zip code of the management company's address.

Check this box if the facility will be operated under a management contract or agreement between the current or proposed owner and a management company.

Check this box if the facility will not be operated under a management contract or agreement between the current or proposed owner and a management company.

Check this box if you wish to apply for the Medi‑Cal (Medicaid) program; if checked, complete Section F (Subcontractor Information and Significant Business Transactions) and provide your NPI where requested.

Check this box if you do not wish to apply for the Medi‑Cal (Medicaid) program.

Enter the National Provider Identifier (NPI) number for the provider if you are applying for the Medi-Cal (Medicaid) program. Fill only if 'Do you wish to apply for the Medi‑Cal (Medicaid) program? — Yes' is 'Yes'.

Provide the full name of the Medical Director.

Enter the professional license number for the Medical Director.

Indicate the expiration date of the Medical Director's professional license.

Enter the date the Medical Director was hired.

Check this box if you wish to apply for the Medicare program.

Check this box if you do not wish to apply for the Medicare program.

Enter the Medicare provider number assigned to your facility by the Medicare program. Fill only if 'Medicare program application — Yes' is 'Yes'.

Enter the name or code of the fiscal intermediary you choose to process Medicare claims for your facility. Fill only if 'Medicare program application — Yes' is 'Yes'.

Enter the facility's National Provider Identifier issued for billing and identification purposes. Fill only if 'Medicare program application — Yes' is 'Yes'.

Check this box if the individual is a 5 percent or greater owner of the subcontractor.

Check this box if the individual is related to any individual identified in Section C.5 that has 5 percent or more ownership or control interest, or any partnership interest, in the Licensee.

Check this box if the individual is not related to any individual identified in Section C.5 that has 5 percent or more ownership or control interest, or any partnership interest, in the Licensee.

Check this box if the related individual is a spouse.

Select 'Yes' if the licensee is a subsidiary of another organization.

Check this box if the licensee is not a subsidiary of another organization.

Check this box if the individual listed in section 'c' is related to another listed person as a spouse, parent, child, or sibling.

Check this box if the individual listed in section 'c' is not related to another listed person as a spouse, parent, child, or sibling.

Check this box if the individual listed in section 'd' is related to another listed person as a spouse, parent, child, or sibling.

Check this box if the individual listed in section 'd' is not related to another listed person as a spouse, parent, child, or sibling.

Check this box if the individual is an owner with 5 percent or greater ownership percentage. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Check this box if the individual's role is a Partner. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Check this box if the Licensee (as named in Section B.1 of the HS200) has 5 percent or more (direct or indirect) ownership interest and/or control interest in any of its subcontractors that provide healthcare services or goods.

Check this box if the Licensee (as named in Section B.1 of the HS200) does not have 5 percent or more (direct or indirect) ownership interest and/or control interest in any of its subcontractors that provide healthcare services or goods.

Check this box if any of the entities (as named in Section B.6 of the HS200) have 5 percent or more (direct or indirect) ownership interest and/or control interest in any of the Licensee's subcontractors that provide healthcare services or goods.

Check this box if none of the entities (as named in Section B.6 of the HS200) have 5 percent or more (direct or indirect) ownership interest and/or control interest in any of the Licensee's subcontractors that provide healthcare services or goods.

Check this box if any of the individuals (as named in Section C.5 of the HS200) have 5 percent or more (direct or indirect) ownership interest and/or control interest in any of the Licensee's subcontractors that provide healthcare services or goods.

Check this box if none of the individuals (as named in Section C.5 of the HS200) have 5 percent or more (direct or indirect) ownership interest and/or control interest in any of the Licensee's subcontractors that provide healthcare services or goods.

Enter the street address and number for the ownership interest holder. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Enter the city for the ownership interest holder's address. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Enter the state for the ownership interest holder's address. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Enter the 9-digit zip code for the ownership interest holder's address. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Enter the full legal name of the person or entity with 5 percent or more ownership or control interest in the subcontractor.

Enter the phone number of the ownership interest holder.

Enter the street number and name of the ownership interest holder's address.

Enter the city of the ownership interest holder's address.

Enter the state of the ownership interest holder's address.

Enter the 9-digit zip code of the ownership interest holder's address.

Enter the full legal name of the person or entity with 5 percent or more direct or indirect ownership interest and/or control interest in the subcontractor. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Enter the phone number of the ownership interest holder. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Enter the ownership percentage for the individual or entity with the subcontractor. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Enter the title of the individual if they are a Director or Officer with the subcontractor. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Enter any other role the individual has with the subcontractor not listed above. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Check this box if the first individual listed in section 5.a is related to another person in the ownership group as a spouse, parent, child, or sibling.

Check this box if the first individual listed in section 5.a is not related to another person in the ownership group as a spouse, parent, child, or sibling.

Check this box if the second individual listed in section 5.b is related to another person in the ownership group as a spouse, parent, child, or sibling.

Check this box if the second individual listed in section 5.b is not related to another person in the ownership group as a spouse, parent, child, or sibling.

Enter the total number of additional sheets attached for subcontractor information. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Provide the total number of additional pages attached for Part B information. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Enter the total number of additional pages attached for Part C.

Enter the total number of additional pages attached for Part D.

Enter the street number and street name for the physical address of the licensee.

Enter the city for the physical address of the licensee.

Enter the state for the physical address of the licensee.

Enter the 9-digit zip code for the physical address of the licensee.

Check this box if the licensee was suspended from the Medi-Cal program and you are providing details for the first applicable program.

Check this box if the licensee was suspended from the Medicaid program and you are providing details for the first applicable program.

Check this box if the licensee was suspended from the Medicare program and you are providing details for the first applicable program.

Check this box if the licensee was suspended from the Medi-Cal program and you are providing details for the second applicable program.

Check this box if the licensee was suspended from the Medicaid program and you are providing details for the second applicable program.

Check this box if the licensee was suspended from the Medicare program and you are providing details for the second applicable program.

Enter the full name of the Program Director.

Enter the professional license number for the Program Director.

Enter the expiration date for the Program Director's professional license.

Enter the date when the Program Director was hired.

Check this box if the Program Plan has been approved by the California Department of Developmental Services (DDS).

Check this box if the Program Plan has not been approved by the California Department of Developmental Services (DDS).

Enter the name of the property owner as it appears on official real estate records.

Provide the street number and name for the property owner's address.

Enter the city for the property owner's address.

Enter the state for the property owner's address.

Enter the 9-digit zip code for the property owner's address.

Select 'Own' if the property is owned by the applicant and submit evidence of control of property.

Select 'Rent' if the property is rented by the applicant and submit evidence of control of property.

Select 'Lease' if the property is leased by the applicant and submit evidence of control of property.

Select 'Sublease' if the property is subleased by the applicant and submit evidence of control of property.

Select 'Other' if the property is controlled by the applicant through other means and submit evidence of control of property.

Provide the specific type of property ownership if it is not 'Own', 'Rent', 'Lease', or 'Sublease'.

Please enter the proposed name for the facility, agency, or clinic.

Provide the street number and name for the proposed mailing address.

Provide the city for the proposed mailing address.

Provide the state for the proposed mailing address.

Provide the 9-digit zip code for the proposed mailing address.

Provide the telephone number for the proposed mailing address.

Enter the street number and street name of the proposed physical location.

Enter the city of the proposed physical location.

Enter the state of the proposed physical location.

Enter the 9-digit zip code for the proposed physical location.

Enter the telephone number for the proposed physical location.

Enter the email address for the proposed physical location.

Enter the fax number for the proposed physical location.

Check this box if the individual is related to any individual identified in Section C.5 that has 5 percent or more (direct or indirect) ownership interest and/or control interest or any partnership interest, in the Licensee identified in Section B.1.

Check this box if the individual is not related to any individual identified in Section C.5 that has 5 percent or more (direct or indirect) ownership interest and/or control interest or any partnership interest, in the Licensee identified in Section B.1.

Check this box if the related individual's relationship is Spouse.

Check this box if the related individual's relationship is Parent.

Check this box if the related individual's relationship is Child.

Check this box if the related individual's relationship is Sibling.

Check this box if the related individual's relationship is Other and specify the relationship.

Specify the type of relationship if it is not a spouse, parent, child, or sibling.

Enter the full name of the related individual.

Check this box if the individual's role with the subcontractor is a 5 percent or greater owner, and specify the ownership percentage.

Enter the type of relationship if it is not one of the listed options (Spouse, Parent, Child, Sibling).

Enter the full legal name of the related individual.

Enter the specific relationship of the individual if it is not one of the listed options (Spouse, Parent, Child, Sibling).

Check this box if the related individual is a spouse.

Check this box if the related individual is a parent.

Check this box if the related individual is a sibling.

Check this box if the related individual is a type of relation not listed above.

Check this box if the individual's role with the subcontractor is a managing employee. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Check this box if the individual's role with the subcontractor is a Director or Officer, and provide their title in the accompanying field. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Check this box if the individual's role with the subcontractor is not listed above, and specify the role in the accompanying field. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Check this box if the individual's role with the subcontractor is a Partner, with 5 percent or greater ownership.

Check this box if the individual's role with the subcontractor is a Managing Employee, with 5 percent or greater ownership.

Check this box if the individual's role with the subcontractor is a Director or Officer, with 5 percent or greater ownership.

Check this box if the individual's role with the subcontractor is an Other role not explicitly listed, with 5 percent or greater ownership.

Enter the ownership percentage of the subcontractor.

Provide the title of the director or officer for the subcontractor.

Describe any other role the individual holds with the subcontractor.

If you answered 'Yes' to the previous question, select this option if the related individual is a spouse.

If you answered 'Yes' to the previous question, select this option if the related individual is a parent.

If you answered 'Yes' to the previous question, select this option if the related individual is a child.

If you answered 'Yes' to the previous question, select this option if the related individual is a sibling.

If you answered 'Yes' to the previous question, select this option if the related individual has a different type of relationship not listed.

Enter the full name of the second facility.

Enter the type or classification of the second facility.

Enter the street number and name for the second facility's address.

Enter the city for the second facility's address.

Enter the state for the second facility's address.

Enter the 9-digit zip code for the second facility's address.

Check this box if the second facility listed is participating in the Medi-Cal program.

Check this box if the second facility listed is not participating in the Medi-Cal program.

Enter the name of the second facility, agency, or clinic.

Enter the street number and street name for the second facility.

Enter the city of the second facility.

Enter the state of the second facility.

Enter the 9-digit zip code for the second facility.

Enter the dates of involvement with the second facility, agency, or clinic.

Enter the amount or description of the second fine or debt.

Enter the name of the agency to which the second fine or debt is owed.

Enter the date the second fine or debt was issued.

Enter the date by which the second fine or debt is to be paid in full.

Enter the full name of the second individual with ownership interest.

Provide the ownership percentage of the second individual.

Describe the relationship of the second individual to any other person listed with ownership interest.

Enter the full name of the second individual.

Enter the ownership percentage of the second individual.

Enter the street number and name for the second individual's address.

Enter the city for the second individual's address.

Enter the state for the second individual's address.

Enter the 9-digit zip code for the second individual's address.

Enter the printed name of the second signatory.

Enter the date the second signatory signed.

Enter the full legal name of the person or entity with 5 percent or more ownership interest and/or control interest in the subcontractor.

Enter the phone number of the second owner or controller.

Enter the street number and name for the second owner or controller's address.

Enter the city for the second owner or controller's address.

Enter the state for the second owner or controller's address.

Enter the 9-digit zip code for the second owner or controller's address.

Enter the full legal name of the person or entity with 5 percent or more direct or indirect ownership or control interest in the second subcontractor.

Provide the phone number for the person or entity associated with the second subcontractor's ownership.

Enter the street number and street name for the address of the person or entity associated with the second subcontractor's ownership.

Enter the city for the address of the person or entity associated with the second subcontractor's ownership.

Enter the state for the address of the person or entity associated with the second subcontractor's ownership.

Enter the 9-digit zip code for the address of the person or entity associated with the second subcontractor's ownership.

Enter the name of the second subsidiary organization.

Enter the federal tax identification number for the second subsidiary organization.

Enter the street number and name of the second subsidiary organization's address.

Enter the city of the second subsidiary organization's address.

Enter the state of the second subsidiary organization's address.

Enter the 9-digit zip code of the second subsidiary organization's address.

Enter the NPI and/or provider number(s) for the second suspension program.

Enter the effective date of the second suspension.

Enter the date of reinstatement for the second suspension, if applicable.

Provide the specific relationship of the second individual if it is not a spouse, parent, child, or sibling.

Enter the full name of the second related individual.

Check this box if Service A is identified under the statute and provided by the facility.

Check this box if Service B is identified under the statute and provided by the facility.

Check this box if Service C is identified under the statute and provided by the facility.

Enter the full name of the sub-lessee.

Enter the sub-lessee's address, including the number and street.

Enter the city of the sub-lessee's address.

Enter the state of the sub-lessee's address.

Enter the 9-digit zip code of the sub-lessee's address.

Enter the city name for the facility address. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Enter the state for the facility address. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Enter the 9-digit zip code for the facility address. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Enter the subcontractor's federal employer identification number, if applicable. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Enter the subcontractor's corporation number, if applicable. Fill only if 'Ownership interest in subcontractor (Part A)' is 'Yes'.

Enter the full legal name of the subcontractor.

Enter the phone number of the subcontractor.

Enter the street number and street name of the subcontractor's address.

Check this box if no subcontractors are listed in Part C of the F-1 attachment, or if the Licensee had no business transactions with subcontractors involving health care services for Medi-Cal beneficiaries exceeding $25,000 in the last 12 months.

Provide the full legal name of the person or entity with 5 percent or more ownership or control interest in the subcontractor.

Enter the phone number of the subcontractor owner.

Provide the street number and street name of the subcontractor owner's address.

Enter the city of the subcontractor owner's address.

Enter the state of the subcontractor owner's address.

Provide the 9-digit zip code of the subcontractor owner's address.

Check this box if the individual's role with the subcontractor is a Partner.

Check this box if the individual's role with the subcontractor is a Managing Employee.

Check this box if the individual's role with the subcontractor is Director or Officer.

Check this box if the individual's role with the subcontractor is other than Director, Officer, Partner, or Managing Employee.

Check this box if the individual is related to any individual identified in Section C.5 who has 5 percent or more ownership or control interest, or any partnership interest, in the Licensee.

Check this box if the individual is not related to any individual identified in Section C.5 who has 5 percent or more ownership or control interest, or any partnership interest, in the Licensee.

Enter the street number and street name of the subcontractor's or supplier's address.

Enter the city of the subcontractor's or supplier's address.

Enter the state of the subcontractor's or supplier's address.

Enter the 9-digit zip code of the subcontractor's or supplier's address.

Enter the full legal name of the subcontractor or supplier.

Enter the phone number of the subcontractor or supplier.

Enter the name of the third facility.

Enter the type of the third facility.

Enter the street number and name for the third facility's address.

Enter the city of the third facility.

Enter the state of the third facility.

Enter the 9-digit zip code for the third facility.

Check this box if the third facility listed is participating in the Medi-Cal program.

Check this box if the third facility listed is not participating in the Medi-Cal program.

Enter the name of the third facility, agency, or clinic.

Provide the street number and name for the third facility's address.

Enter the city for the third facility's address.

Enter the state for the third facility's address.

Enter the 9-digit zip code for the third facility's address.

Provide the dates of involvement for the third facility.

Enter the full name of the third individual with ownership interest.

Enter the ownership percentage for the third individual.

Describe the relationship of the third individual to other persons listed, if applicable.

Enter the full name of the third individual.

Enter the ownership percentage of the third individual.

Enter the street number and street name for the third individual's address.

Enter the city of the third individual's address.

Enter the state of the third individual's address.

Enter the 9-digit zip code of the third individual's address.

Check this box if the third owner/controller is a 5 percent or greater owner with an ownership percentage in the subcontractor.

Check this box if the third owner/controller is a partner in the subcontractor.

Check this box if the third owner/controller is a managing employee of the subcontractor.

Check this box if the third owner/controller is a director or officer of the subcontractor.

Check this box if the third owner/controller has a role other than the listed options in the subcontractor.

Check this box if the third owner/controller is related to any individual identified in Section C.5 with 5 percent or more ownership/control interest or any partnership interest in the Licensee.

Check this box if the Third Owner/Controller is not related to any individual identified in Section C.5 that has 5 percent or more ownership/control interest or any partnership interest in the Licensee identified in Section B.1.

Check this box if the Third Owner/Controller is related as a spouse to an individual identified in Section C.5 that has 5 percent or more ownership/control interest or any partnership interest in the Licensee identified in Section B.1.

Check this box if the Third Owner/Controller is related as a parent to an individual identified in Section C.5 that has 5 percent or more ownership/control interest or any partnership interest in the Licensee identified in Section B.1.

Check this box if the Third Owner/Controller is related as a child to an individual identified in Section C.5 that has 5 percent or more ownership/control interest or any partnership interest in the Licensee identified in Section B.1.

Check this box if the Third Owner/Controller is related as a sibling to an individual identified in Section C.5 that has 5 percent or more ownership/control interest or any partnership interest in the Licensee identified in Section B.1.

Check this box if the Third Owner/Controller is related to an individual identified in Section C.5 that has 5 percent or more ownership/control interest or any partnership interest in the Licensee identified in Section B.1, and their relationship is not spouse, parent, child, or sibling.

Provide the printed name of the third individual signing the declaration.

Provide the job title of the third individual signing the declaration.

Enter the full legal name of the third subcontractor or entity with 5 percent or more ownership or control interest.

Enter the phone number of the third subcontractor.

Enter the street number and name of the third subcontractor's address.

Enter the city of the third subcontractor's address.

Enter the state of the third subcontractor's address.

Enter the 9-digit zip code of the third subcontractor's address.

Provide a detailed description of the transaction(s).

Check this box if you are submitting a first-time (initial) application for licensure or certification for a new facility/agency/clinic.

Check this box if you are submitting an initial application to add a branch location for a Home Health Agency.

Check this box if you are submitting an initial application to add multiple locations for a Hospice Agency.

Check this box if the application is being filed because of a change of ownership of the facility (see section #2 for additional requirements).

Check this box if the application concerns a management company arrangement or change (refer to Sections C1, E, G, and Attachment E-1 for details).

Check this box if you are applying to reinstate a license that was suspended.

Check this box if the application is for a change not listed above (select Other Change and complete Section A3).

Check this box if there has been a change in the facility's licensed bed count or bed configuration.

Check this box if the classification or type of beds (for example skilled vs. intermediate) assigned to the facility has changed.

Enter the new bed classification or code that reflects the updated category for the facility’s beds (e.g., specialty or level of care) as a short text or code. Fill only if 'b. Change of Bed Classification' is 'Yes'.

Check this box if the facility's capacity (such as the number of patients or residents the facility is licensed to serve) has changed.

Check this box if you are adding a new certification or certification category to the facility's license.

Check this box if the type or classification of the facility (for example clinic vs. hospital) has changed.

Enter the new facility type or classification (a short descriptive name or code) that identifies the facility’s updated operational type. Fill only if 'e. Change of Facility Type' is 'Yes'.

Check this box if the geographic area served by the facility (service area boundaries) has changed.

Check this box if there has been a change in the facility's governing board membership or governance structure.

Check this box if an indirect owner (an owner who holds interest through another entity) of the facility has changed.

Check this box if the facility is relocating or its physical location is changing (not merely the mailing address).

Check this box if only the facility's mailing address has changed or will change.

Check this box if the official name of the facility, agency, or clinic has changed.

Check this box if the facility's National Provider Identifier (NPI) number has changed.

Check this box if ownership of the facility's property has transferred to a different property owner.

Check this box if there has been a change in the types of services the facility provides.

Enter the brief description or code that specifies the nature of the change of service being reported (e.g., the specific service added, removed or modified). Fill only if 'Change of Service' is 'Yes'.

Check this box if the change of ownership occurred via a transfer of stock.

Check this box if the type of change is not listed among the options and provide a description or attachments as required.

Provide a short description of any other type of change not listed above, clearly describing what has changed. Fill only if 'Other' is 'Yes'.

Check this box if the entity is a for-profit corporation.

Check this box if the entity is a general partnership.

Check this box if the entity is a city government.

Check this box if the entity is a county government.

Check this box if the entity is a state agency.

Check this box if the entity is a public agency.

Check this box if the entity is another type of governmental agency not specifically listed.

Provide the specific type of other governmental agency not listed.

Check this box if the entity is a Limited Liability Company (LLC).

Check this box if the entity is a limited liability partnership.

Check this box if the entity is a limited partnership.

Check this box if the entity is a nonprofit corporation.

Check this box if the entity is an unincorporated nonprofit association.

Check this box if the entity is a charitable nonprofit organization.

Check this box if the entity is a religious nonprofit organization.

Check this box if the entity is another type of nonprofit organization not specifically listed.

Provide the specific type of other nonprofit entity not listed.

Check this box if the entity is a sole proprietorship (individual).

Provide the specific type of other entity not listed.

Check this box if the entity type is not listed among the other options.

Check this box if the facility applying for licensure/certification is an Acute Psychiatric Hospital (APH).

Check this box if the facility is an Adult Day Health Center (ADHC).

Check this box if the facility is an Alternative Birth Center (ABC).

Check this box if the facility is an Ambulatory Surgery Center (ASC).

Check this box if the facility is a Chemical Dependency Recovery Hospital (CDRH).

Check this box if the facility is a Chronic Dialysis Clinic (CDC).

Check this box if the facility is a Chronic Dialysis Clinic or provides End Stage Renal Dialysis (CDC/ESRD).

Check this box if the facility is a Community Clinic (COMTYC).

Check this box if the facility is a Community Clinic or Rural Health Clinic (COMTYC/RHC).