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CDPH Releases Reports on Healthcare-Associated Infections, Influenza Vaccination Rates Among Healthcare Personnel CDPH Warns Consumers Not to Eat … If information on the officers or board members is incorrect because the information has changed, resubmit the Administrative Organization form (HS 309). Sacramento, CA 95899-7377, For General Public Information: Reset MS 0500 (1-833-422-4255). 850 18 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 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Please refer to CDPH website. Street Address City, State, Zip Code. Fill out, securely sign, print or email your cdph form instantly with SignNow. Cal Health Find provides health care consumers and providers with information about licensed and certified facilities throughout California. (1-833-422-4255). The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. Español, - It looks like your browser does not have JavaScript enabled. This tutorial video guides applicants on how to complete the HS 309 form. Training videos are available for the following forms: Licensure & Certification Application Form (HS 200) Applicant Individual Information (HS 215A) Hs 200. 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. "Licensure & Certification Application," HS 200 (2/08), signed by the provider or legal representative. 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.10.a. HS 200 (02/2008) – Licensure and Certification Application HS 215A (02/2008) – Applicant Individual Information HS 309 (10/2011) – Administrative Organization Decrease, Reset Learn more about how to protect yourself and your family. HS Division, Room 200 : 9200 Valley View Street : Cypress : 90630 (714 ) 484 -7000 47286 : East Los Angeles Occupational Center Allied Health ; 2100 Marengo Street : Los Angeles : 90033 (323 ) 276 -7000 Page 1 of 7 californiahealth and human services agency communitycare licensingdivision californiadepartmentof social services homecare services bureau. * In addition to the HS 200 instructions, use the guidance and assistance provided below when completing the form. "Licensure & Certification Application," HS 200 (2/08), signed by the provider or legal representative. Start a free trial now to save yourself time and money! 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 530. 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. 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. Cdph 5000 Form. BCIA 8016 Sample FIU (PDF) - Request for Live Scan Service, CDPH 171 (PDF) - 40 Hour Home Health Aide (HHA) Training Program Application, CDPH 171 A (PDF) - 40 Hour Home Health Aide (HHA) Training Program Current Curriculum, CDPH 171 B (PDF) - 40 Hour Home Health Aide (HHA) Training Program Faculty Application, CDPH 183 (PDF) - Home Health Aide (HHA) Certification List, CDPH 191 (PDF) - 120 Hour Home Health Aide (HHA) Training Program Application, CDPH 191 A (PDF) - 120 Hour Home Health Aide (HHA) Training Program Current Curriculum, CDPH 191 B (PDF) - 120 Hour Home Health Aide (HHA) Training Program Faculty Application, CDPH 192 (PDF) - Application for Initial/Renewal Approval as a Continuing Education (CE) Provider, CDPH 192 B (PDF) - Application for Initial/Renewal Approval as an Online Continuing Education Provider, CDPH 193 (PDF) - Facility/School Contact Information, CDPH 241 (PDF) - Application for Cardiovascular Surgery Service, CDPH 242 (PDF) - Application for Chronic Dialysis Service, CDPH 243 (PDF) - Application for Dental Service, CDPH 245 (PDF) - Application for Nuclear Medicine Service, CDPH 246 (PDF) - Application for Outpatient Service, CDPH 247 (PDF) - Application for Pediatric Service, CDPH 248 (PDF) - Application for Perinatal Unit, CDPH 249 (PDF) - Application for Podiatric Service, CDPH 250 (PDF) - Application for Psychiatric Unit, CDPH 251 (PDF) - Application for Radiation Therapy Service, CDPH 252 (PDF) - Application for Renal Transplant Center, CDPH 253 (PDF) - Application for Respiratory Care Service, CDPH 255 (PDF) - Application for Social Service, CDPH 256 (PDF) - Application for Standby Emergency Medical Service, Physician on Call, CDPH 257 (PDF) - Application for Basic Emergency Medical Service, Physician on Duty, CDPH 258 (PDF) - Application for Comprehensive Emergency Medical Service, CDPH 259 (PDF) - Application for Rehabilitation Center, CDPH 260 (PDF) - Application for Occupational Therapy Service, CDPH 261 (PDF) - Application for Physical Therapy Service, CDPH 262 (PDF) - Application for Speech Pathology and/or Audiology Service, CDPH 263 (PDF) - Application for Acute Respiratory Care Service, CDPH 264 (PDF) - Application for Burn Center, CDPH 265 (PDF) - Application for Coronary Care Service, CDPH 266 (PDF) - Application for Intensive Care Newborn Nursery Service, CDPH 267 (PDF) - Application for Intensive Care Service, CDPH 268 (PDF) - Application for Supplemental Services Approval, CDPH 270 (PDF) - Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital, CDPH 272 (PDF) - Elective Percutaneous Coronary Intervention (PCI) Program Application, CDPH E276 (PDF) - Online Nurse Assistant Training Program Application, CDPH 276 A (PDF) - Nurse Assistant Training Program Skills Check List Sample, CDPH E276 A (PDF) - Online Nurse Assistant Training Program Skills Checklist, CDPH 276 B (PDF) - Daily Nurse Assistant Training Program Schedule, CDPH E276 B (PDF) - Online Nurse Assistant Training Program Daily Clinical Schedule, CDPH 276 B Sample (PDF) -Daily Nurse Assistant Training Program Schedule Sample, CDPH 276 C (PDF) - Nurse Assistant Certification Training Program Individual Student Record, CDPH E276 C (PDF) - Online Nurse Assistant Certification Training Program Individual Student Record, CDPH 276 D (PDF) - Disclosure of Ownership and Control Interest Statement, CDPH 276 E (PDF) - Nurse Assistant Training Program and/or Home Health Aide Program Clinical Site Agreement, CDPH E276 E (PDF) - Online Nurse Assistant Training Program Clinical Training Site Agreement, CDPH 276 F (PDF) - Skilled Nursing Facility (SNF) Nurse Assistant Certification Training Program Application, CDPH 276 P (PDF) - Instructions for Development and Implementation of Policies and Procedures by Nurse Assistant Training Program Applicants, CDPH E276 P (PDF) - Online Nurse Assistant Training Program Sample Policies and Procedures, CDPH 276 S (PDF) - School Nurse Assistant Certification Training Program Application, CDPH 278 A (PDF) - Nurse Assistant Orientation Program Content, CDPH 278 B (PDF) - In-Service Training Program, CDPH 278 C (PDF) - Facility Declaration of Participation in Approved Training Programs, CDPH E278 C (PDF) - Facility Declaration of Participation in Approved Online Training Program, CDPH 278 SC (PDF) - Option 2 Nurse Assistant Pre-Certification Training Contract, CDPH E278 SC (PDF) - Option 2 Online Nurse Assistant Training Program Sample Contract, CDPH 279 (PDF) - Instructor or Director of Staff Development (DSD) Application, CDPH E279 (PDF) - Online Nurse Assistant Training Program Instructor or Director of Staff Development Application, CDPH 283 A (PDF) - Certified Nurse Assistant (CNA), Home Health Aide (HHA), In-Service Training/Continuing Education Units (CEUs), CDPH 283 B (PDF) - Certified Nurse Assistant (CNA) Initial Application, CDPH 283 C (PDF) - Certified Nurse Assistant (CNA) and/or Home Health Aide (HHA) Renewal Application, CDPH 283 D (PDF) - Home Health Aide (HHA) Initial Application, CDPH 283 F (PDF) - Certified Hemodialysis Technician (CHT) Initial Application, CDPH 283 G (PDF) - Certified Hemodialysis Technician (CHT) Renewal Application, CDPH 283 I (PDF) - Transmittal for Criminal Background Clearance, CDPH E299 (PDF) - Online Nurse Assistant Training Program Curriculum Vendor Application, CDPH 310 (PDF) - MDS 3.0 Section S California, CDPH 318 (PDF) - CNA/HHA/CHT Report of Misconduct, CDPH 322 (PDF) - Transmittal Application for Criminal Record Clearance, CDPH 325 (PDF) - Criminal Record Clearance Submissions, CDPH 327 (PDF) - California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities, CDPH 391 (PDF) - Hemodialysis Technician/Patient Care Technician Training Program Application, CDPH 414 (PDF) - Application for Health Facility/Agency Change of Location, CDPH 501 (PDF) - Administrator in Training (AIT) Evaluation Report, CDPH 502 (PDF) - Application for AIT Program, CDPH 502 A (PDF) - Application for Educational Waiver for AIT Program, CDPH 503 (PDF) - Application for Nursing Home Administrator State Examination, CDPH 505 (PDF) - Application for Nursing Home Administrator National Examination, CDPH 506 (PDF) - Application for Nursing Home Administrator License, CDPH 507 (PDF) - Modification of Administrator in Training Hours Request, CDPH 508 (PDF) - Application to Become a Provider of Continuing Education, CDPH 509 (PDF) - Continuing Education Courses Completed for Active License Renewal, CDPH 510 (PDF) - Declaration and Request for Replacement License, CDPH 511 (PDF) - Instructor Application for C.E. 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:  If the licensee, facility, or property information is incorrect because the information has changed, resubmit the L&C Application form (HS 200). Name and Title of Authorized Official (please print or type) Name of Agency Receiving/Requesting Funding. PO Box 997377 Last updated: 1/4/2021 A.8.a. Please do not enclose the licensure fee, there is no fee. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. 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. (916) 558-1784, COVID 19 Information Line: Available for PC, iOS and Android. EF 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 … MS 0500 *If you are having difficulty accessing any of these documents, please contact CDPH at (916) 558-1784 to request information in an alternate format. 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