Form Hs 200 PDF Details

The HS 200 form is a comprehensive document issued by the State of California – Health and Human Services Agency, specifically through the California Department of Public Health Licensing and Certification. Designed for a wide array of facilities including skilled nursing facilities, intermediate care facilities, home health agencies, and many others, the form serves as a licensure and certification application. It encompasses various aspects such as application information, details about changes in ownership, facility, agency or clinic information, and details regarding the licensee. This document also requires disclosure of the facility's financial resources, compliance with local ordinances, and the names and percentages of ownership for individuals with significant interest in the facility. Besides these, it addresses the necessity for construction and the operation under management agreements, underscoring its role in ensuring facilities comply with health and safety standards. The form stands as a vital step in the establishment or continued operation of health care facilities, ensuring that they meet the regulatory requirements set forth by the state. This requirement not only emphasizes the importance of maintaining high standards of care but also facilitates the provision of health services to the community by qualified entities.

QuestionAnswer
Form NameForm Hs 200
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other nameshs200, hs200 form, cdph hs200, hs 200 licensure and certification application

Form Preview Example

State of California – Health and Human Services Agency

 

 

 

 

 

California Department of Public Health

 

 

 

 

 

 

Licensing and Certification

LICENSURE & CERTIFICATION APPLICATION

 

 

 

 

 

 

 

 

FOR DEPARTMENTAL USE ONLY

 

 

 

 

 

 

 

District:

 

ELMS Facility Number:

 

 

 

 

 

 

Proposed name of facility/agency/clinic:

A. APPLICATION INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Type of application (check one):

 

 

 

 

 

 

 

 

a. Initial

c. Management company (see Sections C1-5, F, and Attachment E-1)

 

 

 

 

 

 

b. Change of Ownership (see #2 below)

d. Other change (see Section A4):

 

 

 

 

2.Change of Ownership Only - For Certification Purposes:

We wish to make certain that our records correctly show the effective date of the ownership change for certification.

This date should reflect the actual date on which you took charge of the financial management of the facility rather than the date of sale or date of state license change. Effective date of change:

3.Amount of fee enclosed: $

4.Type of Change (check all that apply):

a.

Not applicable

f.

Change of bed classification

b.

Change of capacity (see # 8 below)

g. Change of name

c.

Change of location

h. Construction of new or replacement facility

d.

Change of services

i.

Stock transfer

 

e.

Change of facility type

j.

Other (specify)

 

5. Type of facility, agency, or clinic (check one)

 

 

 

 

a.

Skilled Nursing Facility (SNF)

i. Rural health clinic (for Certification “only”)

b.

Intermediate Care Facility (ICF)

j. General acute care hospital

c.

ICF/Developmentally Disabled (ICF/DD)

k. Adult day health care center

d.

ICF/DD-Habilitative (ICF/DD-H)

l.

 

Home Health Agency (HHA)

e.

ICF/DD-Nursing (ICF/DD-N)

m. Hospice

 

f.

Primary care clinic – Free

n.

 

Chronic dialysis clinic

g.

Primary care clinic – Community

o.

 

Other (specify)

h.

Surgical clinic

 

 

 

 

6. a.

Do you wish to apply for the Medicare program?

Yes

No Medicare Provider #:

b.Fiscal Intermediary choice:

7. Do you wish to apply for the Medi-Cal (Medicaid) program?

Yes

No

8. a. Current facility bed capacity:

b.Proposed facility bed capacity:

9. Age range of clients:

10. Days and hours of operation:

11. Is construction required? Yes No

If "yes", submit copy of “OSHPD” form (see instructions on page 6)

If "yes", date construction to begin:

If "yes", date construction to be completed:

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B. LICENSEE INFORMATION

1. Licensee name:

2.Federal employer’s tax ID number:

3.Owner type (check one): Submit organizational chart for b, c, d, and e.

a.

Sole proprietorship (Individual)

g.

City

 

b.

Profit corporation

h.

County

 

c.

Nonprofit corporation

i.

State agency

 

d.

Limited Liability Company (LLC)

j.

Other agency (specify)

 

e.

Partnership – General

k. Public agency (specify)

 

f.

Partnership – Limited

 

 

 

4. Licensee address (number & street):

 

 

Telephone number:

City, State, & Zip:

 

E-Mail:

Fax number:

5.a. Identify other facilities, agencies, or clinics the licensee has been licensed for, operated, managed, held a 5% or more interest in, or served as a director or officer. Include facilities both in and outside of California. Submit an attachment for additional facilities that includes all of the required information listed below.

(1)Facility Name:

Facility address (number & street):

Facility Type:

City, State, & Zip:

(2)Facility Name:

Facility address (number & street):

Facility Type:

City, State, & Zip:

(3)Facility Name:

Facility address (number & street):

Facility Type:

City, State, & Zip:

(4)Facility Name:

Facility address (number & street):

Facility Type:

City, State, & Zip:

b.If any facility, agency, or clinic identified in 5.a. has had a license revocation action filed, license placed on probation, suspended, or revoked (whether stayed or not) or, for agency or clinic resolved by settlement, receiver appointed, or had a final Medi-Cal decertification action taken, please submit additional information, including all ownership and facility information, date and any final action.

6. Is the licensee a subsidiary of another organization?

Yes

No

If “yes”, complete the information below and submit an organizational chart:

 

 

Parent organization name:

Parent federal tax ID Number:

P.O. Box or number & street:

City, State, & Zip:

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C. FACILITY, AGENCY OR CLINIC INFORMATION

Management Agreement (this only applies to SNF's & ICF's):

 

1. a. Is the facility, agency, or clinic going to be operated under a management contract/agreement

Yes

between the proposed owner and a management company?

 

If “yes”, proceed to Section E (below).

No

 

 

b. Is there an “interim” management agreement, between the proposed owner and the current

Yes

owner, to run the facility, agency, or clinic until the change of ownership is completed?

 

If “yes”, submit a copy of the “interim” management agreement.

No

2.Name of “proposed” facility, agency, or clinic:

Current facility, agency, or clinic name (if change of ownership):

 

 

 

 

 

 

 

 

Facility license number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

Address (number & street) of “proposed” facility, agency, or clinic:

 

Telephone number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City, State, & Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

Mailing address, if different from above:

 

 

 

 

Telephone number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number & Street:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax number:

 

E-mail address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City, State, & Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.Name of person to be in charge of facility, agency, or clinic:

Title:

 

Professional License number:

6. a. Name of administrator: Professional License number:

b. Name of director of nursing:

Professional License number:

Date of hire: Expiration date: Date of hire: Expiration date:

7.List persons having 5 percent or more direct or indirect (42 CFR, Section 455.102) interest in the ownership of this facility if applying for skilled nursing or intermediate care licensure, and 10 percent for all other facilities, agencies, or clinics. Provide federal employer's tax ID number. Are any of these persons (listed below) related to one another as spouse, parent, child or sibling? Submit an attachment for additional names that includes all of the required

information listed below.

 

Are they related to one another as

Name of individual

% Owned EIN Number a spouse, parent, child or sibling? Relationship

(1)

Yes

No

(2)

Yes

No

(3)

Yes

No

(4)

Yes

No

(5)

Yes

No

8.Financial resources -- Only applies to SNF and ICF:

Submit evidence, i.e., bank statements, line of credit, certificate(s) of deposit, satisfactory to the department(s) that the licensee possesses financial resources sufficient to operate the facility for a period of at least 45 days. (The amount is determined by multiplying 45 days X number of beds X rate).

9.Over-concentration -- Only applies to ICF/DD, ICF/DD-H and ICF/DD-N:

a. Are there any ICF/DD, ICF/DD-H, ICF/DD-N, RCF (residential care facility), or pediatric day health or respite

care facilities within 300 feet of this facility? (H&S Code, Section 1267.9)

Yes No Don’t know

b.Are there any congregate living health facilities within 1,000 feet of this facility? Yes No Don’t know

10.Program Plan -- Only applies to ICF/DD, ICF/DD-H and ICF/DD-N (H&S Code, Section 1275.3(b)(3))

Has the program plan been approved by the Department of Developmental Services? Yes No

If “yes”, Submit a copy of the approval letter. The “current licensee” can grant permission for their Program Plan to be used for 6 months if they submit a letter to CDPH. If “no”, the application package will be delayed until a copy of the approved program letter is received.

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D. PROPERTY INFORMATION

1. Property ownership: Check one and submit evidence of control of property: Own Rent Lease

Sublease

Other (specify):

2. Owner of Record name in the real estate: Address (number & street):

City, State, & Zip:

Lessee name:

Address (number & street):

City, State, & Zip:

Sub-Lessee name:

Address (number & street):

City, State, & Zip:

E. MANAGEMENT COMPANY

If the proposed facility, agency, or clinic will be operated by a management company, under a management contract between the proposed owner and a management company, complete Attachment E-1 (next page). NOTE: if the facility is a SNF or ICF, the management company will have to SUBMIT a separate application to the Department, unless previously approved.

F.I (we) Accept responsibility to:

a.Comply with local ordinances concerning zoning, sanitation, building, and other appropriate ordinances.

b.Comply with the Labor Code on employment practices concerning nondiscrimination, liability insurance, wages, hour and working conditions.

c.Comply with Health and Safety Code and regulations concerning licensing and fire safety.

I (we) declare under penalty of perjury that the statements on this application and on the accompanying attachments are correct to my (our) knowledge.

Signature

 

Title

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

Title

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

Title

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

Title

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Release of Information Statement

This information shall be provided to the state department upon initial licensure. Any changes must be provided to the state department within 10 days of the change. The information shall be made available to the public upon request and shall be included in the public file of the facility.

The information provided on this form is mandatory and is necessary for licensure approval. It will be used to determine individual applicants or applicant facility’s ability to provide health services. The information is requested by the California Department of Public Health, Licensing and Certification, in accordance with Health and Safety Code, Sections 1212, 1253, 1265, 1267.5, and 1728, and California Code of Regulations (CCR), Title 22, Sections 70107, 71107, 73205, 74105, 75022, 76205, and 78205.

Failure to provide the information as requested may result in nonissuance of a license or license revocation.

The information is considered public information and will be made available to the public upon request. The information shall be included and maintained in the individual facility’s public files located in Licensing and Certification district offices.

HS 200 (02/08)

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ATTACHMENT E-1

MANAGEMENT COMPANY INFORMATION ONLY FOR SNF's or ICF's

1. Submit a copy of the Management Agreement with this application.

 

 

 

 

 

Name of management company:

 

 

EIN:

 

 

 

Address (number & street):

 

 

 

 

 

City, State, & Zip:

 

 

 

Name of facility to be managed:

Address (number & street): City, State, & Zip:

EIN:

2.Provide the following information for each individual having a 5 percent or more interest in the management company. Submit an attachment for additional names that includes all of the required information listed below.

(1)

Individual’s name:

 

 

% Owner:

 

Address (number & street):

 

 

 

 

 

 

 

 

 

City, State, & Zip:

 

 

 

 

 

 

 

 

(2)

Individual’s name:

 

 

% Owner:

 

 

 

Address (number & street):

 

 

 

 

 

 

 

 

 

City, State, & Zip:

 

 

 

 

 

 

 

 

(3)

Individual’s name:

 

 

 

% Owner:

 

 

 

Address (number & street):

 

 

 

 

 

 

 

 

 

City, State, & Zip:

 

 

 

 

 

 

 

 

(4)

Individual’s name:

 

 

% Owner:

 

 

 

Address (number & street):

 

 

 

 

 

 

 

 

City, State, & Zip:

 

 

 

 

 

 

 

3.Provide a list of all facilities, agencies, or clinics with which you have entered into a management agreement. Submit an attachment for additional facility, agency, or clinic names that includes all of the required information listed below.

(1)Facility, agency, or clinic name:

Address (number & street):

City, State, & Zip:

(2)Facility, agency, or clinic name:

Address (number & street):

City, State, & Zip:

(3)Facility, agency, or clinic name:

Address (number & street):

City, State, & Zip:

(4)Facility, agency, or clinic name:

Address (number & street):

City, State, & Zip:

Dates of involvement:

Dates of involvement:

Dates of involvement:

Dates of involvement:

HS 200 (02/08)

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INSTRUCTIONS

SNF or ICF Management Company Application: See Attachment E-1 below.

Type or print clearly. Return original and maintain a copy for your records. The Licensee's name must be consistent throughout all documents submitted. Submit all supplemental paperwork requested to complete your application. Do not leave items blank. If not applicable, mark N/A.

A. APPLICATION INFORMATION

1.Type of application: select items a, b, c, or d.

If b is selected, provide effective date of change in number 2.

If c is selected, complete Sections C1-5; F, and Attachment E-1.

If d is selected you must select an option in number 4 -- “Type of Change.”

2.Provide actual date applicant took charge of the financial management of facility.

This date is used to show effective date of the ownership change for certification purposes only.

3.Amount of fee enclosed: enter the amount of money enclosed with this application.

If no fee is required, enter “N/A”. (Refer to fee schedule for appropriate fee requirements.)

4.Type of change: check all that apply.

5.Type of facility, agency, or clinic: select the appropriate category.

6.(a) Check “yes” if requesting certification for Medicare. ICF/DD, ICF/DD-N, ICF/DD-H facilities and

primary care clinics that are not certified as rural health clinics are not eligible for Medicare.

(b)If “yes” to item 6(a), provide name of fiscal intermediary under item 6(b).

7.Check “yes” if requesting participation in Medi-Cal (Medicaid).

8.(a) Current facility bed capacity: enter the total number of persons for whom care can currently be provided in any 24-hour period. This figure must agree with the “Certificate of Occupancy”.

(b)Proposed facility bed capacity: enter the proposed total number of persons for whom care will be provided in any 24-hour period.

9.Enter age range of persons to receive/receiving care.

10.Enter days and hours of facility operation.

11.Enter date construction is to begin, and date construction is to be completed (not applicable for

ICF/DD, ICF/DD-N, ICF/DD-H facilities).

Submit a copy of the form “Construction Advisory Board ” (form OSH-FDD 377) if OSHPD has approved construction.

Submit a copy of the above form to the local district office prior to the survey if OSHPD has not yet approved construction.

B. LICENSEE INFORMATION

1. Licensee name: enter the full legal organization name (LLC, partnership, and corporation) or individual(s) responsible for the facility/agency. If “Inc.” is included in your legal name, it must appear in the name. Individuals enter first, middle, and last name. Husband and wife, if joint applicants, must both be listed.

NOTE: All individuals including owners, partners, principal officers of corporations/LLCs, members, managers, and administrators (clinics only) must complete “Applicant Individual Information” (HS 215A).

2. Enter the federal employer’s tax ID number.

3. Owner Type: select one of the options and then:

Submit an organizational chart, for items b, c, d, or e showing entity, persons, facilities, and tax EIN numbers.

Submit a copy of the Internal Revenue Service and Franchise Tax Board letters of determination of nonprofit status, if item c, “nonprofit corporation” is selected, and the facility is a primary care Clinic.

HS 200 (02/08)

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4. Licensee address: enter address of legal organization (LLC, corporation, partnership) or individual(s) responsible for the facility, agency, or clinic. Provide phone number with area code, fax number, and e-mail address.

5. Other Facilities:

(a)Identify all other facilities, agencies, or clinics the licensee (LLC, corporation, partnership, individual) has been involved in, both in and outside of California.

Submit an attachment, if needed, for additional entities, which includes the facility, agency or clinic type (including “affiliate” clinics), name, address, nature of involvement, and dates of involvement. This attachment must include all of the required information listed.

Submit an attachment, if needed, for any entity identified in number 5a, which has had a license revocation action filed, license placed on probation, suspended, or revoked (whether stayed or not) or, for SNFs and ICFs, resolved by settlement, receiver appointed, or has a final Medi-Cal decertification action taken. Include all ownership and facility information, dates, and any final action.

6. Subsidiary: check “yes” if the licensee is a subsidiary of another organization and complete the information requested.

Submit a detailed organizational chart, including parent and all subsidiary information, and federal tax ID numbers.

C.FACILITY, AGENCY, OR CLINIC INFORMATION

1.Management Agreement:

(a)Check “yes” if the facility, agency, or clinic is going to be operated under a management contract/agreement, between the proposed owner and a management company. Proceed to Section “E” (below).

(b)Check “yes” 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.

Submit a copy of the “interim” management agreement, if applicable.

2. Facility, agency, or clinic name: Enter the name used to designate the single facility, agency or clinic under the license being requested. Also, provide the current facility, agency, or clinic name, and current license number (if different). Change of ownership usually results in a name change.

3.Provide facility, agency, or clinic address, including phone number with area code, fax number, and e-mail.

4.Provide facility, agency, or clinic mailing address, if different from number 3 (above).

5.Provide the name and title of the individual to be in charge of the facility, agency, or clinic as well as any professional license number (if applicable).

6.Administrator:

(a)Provide the name of the facility administrator, date of hire, license number, and license expiration date.

(b)Provide the name of the director of nursing services (if applicable), date of hire, license number,

and license expiration date.

7. Provide name(s) of all individuals having a 5 percent or more interest in the ownership of this facility, if applying for SNF or ICF licensure. For all other facility, agency, or clinic types, provide the name(s) of those having 10 percent or more interest in the ownership. Specify how these persons are related to

one another as spouse, parent, child or sibling.

Submit an attachment for all additional names. This attachment must include all of the required information.

8.Financial Resources: Only applies to SNF, ICF, and ICF/DD:

Submit evidence, satisfactory to the Department, that the licensee has sufficient financial resources to operate the facility for at least 45 days (bank statement, certificate of deposit etc.). The amount is determined by multiplying 45 days X number of beds X rate.

9. Over-concentration -- Only applies to ICF/DD, ICF/DD-H and ICF/DD-N:

(a)Are there other ICF/DD, ICF/DD-H, ICF/DD-N residential care, pediatric day health, or respite care facilities within 300 feet of this facility? Check “yes”, “don't know” or “no”.

(b)Are there any congregate living health facilities within 1,000 feet of this facility?

Check “yes”, “don’t know” or “no”.

HS 200 (02/08)

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10. Program Plan -- Only applies to ICF/DD, ICF/DD-H and ICF/DD-N:

Indicate if the program plan has been approved by the Department of Developmental Services. The “current licensee” can grant permission for their Program Plan to be used for 6 months if a letter is submitted to CDPH. If “no” is checked, the application package will be held until a copy of the approved program plan letter is received.

Submit a letter to CDPH from the “current” licensee that the “proposed” licensee has their permission to use the “current” licensee’s Program Plan for up to 6 months, if applicable. Submit a copy of the Program Plan approval letter, if “yes”.

D. PROPERTY INFORMATION

1.Licensee must show evidence of control of property.

Submit a copy of the deed and/or bill of sale, if property is owned. Submit a copy of the rental agreement, if property is rented. Submit a copy of the lease agreement, if property is leased.

Submit a copy of the original lease plus a copy of the sublease, if property is subleased. Submit appropriate evidence if “other” is checked.

2.Provide name and address of the Owner of Record, Lessee and Sub-lessee as applicable.

E. MANAGEMENT COMPANY INFORMATION

(Complete Sections A1, C1-5, F & ATTACHMENT E-1)

F. STATEMENT OF RESPONSIBILITIES

Application must be signed by licensee or authorized representative.

ATTACHMENT E-1

MANAGEMENT COMPANY INFORMATION ONLY FOR SNF's OR ICF's

1. If the proposed facility, agency, or clinic will be operated by a management company, under a management contract between the proposed owner and a management company, provide the name, address, and federal tax ID number of Management Company and name of facility to be managed.

Submit a copy of the Management Agreement.

2.Provide the name, address, and percent of ownership for each person having a 5 percent or more interest in the Management Company.

Submit an attachment for additional names. This attachment must include all of the required information.

3.Provide a list of all facilities, agencies, or clinics that you have contracted to manage.

Submit an attachment for additional facilities, agencies, or clinics. This attachment must include all of the required information.

HS 200 (02/08)

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This document will need you to provide some specific details; in order to ensure correctness, take the time to heed the recommendations directly below:

1. Firstly, once filling in the cdph application, start out with the part that includes the subsequent fields:

Simple tips to complete hs200 stage 1

2. Just after performing the previous step, go to the subsequent step and fill in all required details in these fields - Type of facility agency or clinic, a Skilled Nursing Facility SNF b, i Rural health clinic for, a Do you wish to apply for the, Yes, Medicare Provider, b Fiscal Intermediary choice, Do you wish to apply for the, Yes, a Current facility bed capacity b, Age range of clients, Days and hours of operation, Is construction required, Yes, and If yes submit copy of OSHPD form.

If yes submit copy of OSHPD form, Medicare Provider, and Is construction required in hs200

3. The next part will be simple - fill out all the form fields in B LICENSEE INFORMATION, Licensee name, Federal employers tax ID number, Owner type check one Submit, a Sole proprietorship Individual b, g City h County i State agency j, Licensee address number street, Telephone number, City State Zip, EMail, Fax number, Identify other facilities agencies, Facility Name, Facility Type, and Facility address number street in order to complete this part.

City State  Zip, Identify other facilities agencies, and Federal employers tax ID number inside hs200

4. The following subsection requires your details in the subsequent places: Facility address number street, City State Zip, Facility Name, Facility Type, Facility address number street, City State Zip, Facility Name, Facility Type, Facility address number street, City State Zip, If any facility agency or clinic, Is the licensee a subsidiary of, Yes, If yes complete the information, and Parent organization name. Remember to provide all required info to go forward.

Facility Type, Yes, and Facility Name of hs200

It's easy to make errors when completing the Facility Type, and so make sure you take a second look before you'll finalize the form.

5. This last section to conclude this form is pivotal. You need to fill in the required blank fields, such as Management Agreement this only, between the proposed owner and a, b Is there an interim management, owner to run the facility agency, Yes, Yes, Name of proposed facility agency, Current facility agency or clinic, Facility license number, Address number street of, Telephone number, City State Zip, Mailing address if different from, Telephone number, and Number Street, prior to using the form. Otherwise, it might produce an unfinished and possibly nonvalid paper!

Management Agreement this only, Facility license number, and Number  Street of hs200

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