Please rate Hs 215A Form Rev. 7-2023
The HS 215A form is required as part of a health care facility, agency, or clinic's application packet for state licensing and/or federal certification.
Changes: any changes must be provided to the state department within 10 days of the change.
ID: attach a copy of the Driver's License or State - Issued Identification Card, which must not be expired.
Employment: Section E: please list your complete employment history for the past 10 years.
Signature: the signature and date of this form should be within the last three months and must contain the signature of the individual whom this form is regarding.
| Question | Answer |
|---|---|
| Form Name | HS 215A |
| Form Length | 19 pages |
| Fillable? | Yes |
| Fillable fields | 225 |
| Avg. time to fill out | 38 min |
| Edition | Rev 7/2023 |
| Issuing agency | California Department of Public Health Licensing and Certification |
| Changes | Within 10 days of the change |
| Other names | HS 215A, HS215A, HS 215, HS215, LIC 215, Form HS 215A, California HS 215A, Applicant Individual Information |
| Official source | HS 215A (Rev 7/2023), California Department of Public Health Licensing and Certification |
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Please rate Hs 215A Form Rev. 7-2023
