Question	Answer
Form Name	Form Cdhp 609
Form Length	1 pages
Fillable?	Yes
Fillable fields	86
Avg. time to fill out	17 min 31 sec
Other names	bed request form, blank 609 letter, cdph 609 form, bed request requested

			CLEAR
State of California-Health and Human Services Agency	California Department of Public Health

BED OR SERVICE REQUEST		Date
BED OR SERVICE REQUEST

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)

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): _______________________

Form Cdhp 609 – Fill Out and Use This PDF

Form Cdhp 609 PDF Details