Form Cdhp 609 PDF Details

Form CDHP 609 is a document used to request an exemption from the health plan requirements for the year. The form must be completed and filed with the Department of Employee Trust Funds (ETF) no later than 60 days after the beginning of the year for which the exemption is requested. This form can be used to request an exemption from either or both of the Individual Mandate and/or Employer Mandate. You may also use this form to apply for a premium subsidy if you meet certain eligibility criteria. If you have any questions about this form or how to complete it, please contact ETF at 1-877-533-5020.

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QuestionAnswer
Form NameForm Cdhp 609
Form Length1 pages
Fillable?Yes
Fillable fields86
Avg. time to fill out17 min 31 sec
Other namesbed request form, blank 609 letter, cdph 609 form, bed request requested

Form Preview Example

 

 

 

CLEAR

 

State of California-Health and Human Services Agency

California Department of Public Health

 

 

 

 

 

BED OR SERVICE REQUEST

 

Date

 

 

 

 

 

 

 

 

 

This form is intended to identify the types of beds or services requested for adult day health center, acute psychiatric hospitals, general acute care hospitals, special hospitals and skilled nursing facilities. For new facilities, complete the column marked “Requested Beds.” For existing facilities, complete both columns. The form is to accompany the application form (HS 200) for any new facility, change in capacity, service, or bed classification.

Name of facility

Type

Address (number, street)

City

State

ZIP code

Please enter the number of beds requested for each category:

EXISTING BEDS

REQUESTED BEDS

_____ Acute Respiratory Care Services

_____

Acute Respiratory Care Services

_____ Burn Center

_____ Burn Center

_____ Cardiovascular Surgery Service

_____

Cardiovascular Surgery Service

_____ Coronary Care Unit

_____ Coronary Care Unit

_____

General Acute Care (Unspecified)

_____

General Acute Care (Unspecified)

_____ General Nursing (Long-Term)

_____ General Nursing (Long-Term)

_____ Intensive Care (Newborn)

_____

Intensive Care (Newborn)

_____

Intensive Care Unit

_____

Intensive Care Unit

_____

Pediatric Service

_____

Pediatric Service

_____

Perinatal Unit

_____

Perinatal Unit

_____

Psychiatric Unit

_____

Psychiatric Unit

_____

Rehabilitation Center

_____

Rehabilitation Center

_____ Renal Transplant Center

_____

Renal Transplant Center

_____

Respiratory Care Service

_____

Respiratory Care Service

_____

Skilled Nursing Service (DP)

_____

Skilled Nursing Service (DP)

_____ Other (specify) ______________________

_____ Other (specify) ______________________

_____ Other (specify) ______________________

_____ Other (specify) ______________________

_____

APPROVED CAPACITY

_____

APPROVED CAPACITY (For Departmental use only)

___________________________________________________________________________________________________

Please check services which the facility currently provides or is requesting:

EXISTING SERVICES

REQUESTED SERVICES

_____ Adult Day Program (only applies to an ADHC)

_____ Adult Day Program (only applies to an ADHC)

_____ Basic Emergency Physician on Duty

_____ Basic Emergency Physician on Duty

_____

Cardiovascular Surgery

_____

Cardiovascular Surgery

_____

Chronic Dialysis Service

_____

Chronic Dialysis Service

_____ Comprehensive Emergency

_____ Comprehensive Emergency

_____

Dental Service

_____

Dental Service

_____ Nuclear Medicine Service

_____ Nuclear Medicine Service

_____ Occupational Therapy Service

_____ Occupational Therapy Service

_____

Outpatient Service (i.e. Family Practice, Pediatrics,

_____

Outpatient Service (i.e. Family Practice, Pediatrics,

 

Primary Care, Rural Health Clinic, etc.)

 

Primary Care, Rural Health Clinic, etc.)

 

Specify: _____________________________

 

Specify: ____________________________

 

Specify: _____________________________

 

Specify: ____________________________

_____

Physical Therapy

_____

Physical Therapy

_____

Podiatric Service

_____

Podiatric Service

_____ Radiation Therapy

_____ Radiation Therapy

_____

Social Service

_____

Social Service

_____

Speech Pathology and/or Audiology Service

_____

Speech Pathology and/or Audiology Service

_____ Other (specify): _______________________

_____ Other (specify): _______________________

_____ Other (specify): _______________________

_____ Other (specify): _______________________

CDPH 609 (12/11)

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