Form Cec Rps 1B PDF Details

Facilities looking to make changes in their capacity, service offerings, or bed classifications have a crucial step to complete in the State of California: filling out the CEC RPS 1B form. Governed by the Health and Human Services Agency, specifically the California Department of Public Health, this form serves as an essential tool in communicating the specific needs of facilities like adult day health centers, acute psychiatric hospitals, general acute care hospitals, special hospitals, and skilled nursing facilities. Whether a facility is laying the groundwork for its services or looking to expand, the form requires detailed information, including the number of beds requested across various specialized categories such as Acute Respiratory Care Services, Burn Centers, and Intensive Care Units, among others. Additionally, it covers a broad spectrum of services facilities currently offer or seek to provide, ranging from Adult Day Programs to more specialized medical treatments and rehabilitation services. This comprehensive approach ensures that the state can accurately assess and facilitate the appropriate allocation of resources and services to meet community health needs. Completing this form, which is to accompany the application form HS 200, represents a critical step for facilities in obtaining the necessary approval for operational changes.

QuestionAnswer
Form NameForm Cec Rps 1B
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesCEC RPS 1B cec pre certification application form

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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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The system will expect you to prepare the Acute Respiratory Care Services, Acute Respiratory Care Services, General Acute Care Unspecified, APPROVED CAPACITY Please check, APPROVED CAPACITY For, EXISTING SERVICES, REQUESTED SERVICES, Adult Day Program only applies to, and Adult Day Program only applies to box.

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It's important to put down certain data inside the field Adult Day Program only applies to, Adult Day Program only applies to, Primary Care Rural Health Clinic, Physical Therapy Podiatric, CDPH, Primary Care Rural Health Clinic, and Physical Therapy Podiatric.

Form Cec Rps 1B Adult Day Program only applies to, Adult Day Program only applies to, Primary Care Rural Health Clinic, Physical Therapy  Podiatric, CDPH, Primary Care Rural Health Clinic, and Physical Therapy  Podiatric fields to complete

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