Type of Change (Check all that apply).
Change of ownership: the date should reflect the actual date on which you took charge of the financial management of the facility.
Medi-Cal: do you wish to apply for the Medi-Cal (Medicaid) program? If “yes” complete Section F.
Management company: the management company is required to submit a separate application to the Department for each facility it proposes to manage.
| Question | Answer |
|---|---|
| Form Name | HS 200 |
| Form Length | 32 pages |
| Fillable? | Yes |
| Fillable fields | 497 |
| Avg. time to fill out | 60+ min |
| Edition | 7/2023 |
| Issuing agency | California Department of Public Health, Licensing and Certification |
| Other names | HS 200, HS200, HS-200, Form HS 200, LIC 200, CDPH HS 200, Licensure & Certification Application |
| Official source | HS 200 (Rev. 7/2023), California Department of Public Health Licensing and Certification |
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