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Hs 200. Decrease, Reset HS 200 (PDF) - Licensure and Certification Application. PO Box 997377 Details: State of California- Health and Human Services Agency California Department of Public Health (CDPH) Licensing and Certification Program (L&C) Aide and Technician Certification Section (ATCS) MS 3301, P.O. Age range of clients 10. The HS 200 can be downloaded from the link listed above. Sacramento, CA 95899-7377, For General Public Information: It looks like your browser does not have JavaScript enabled. application for a home care organization license ( ) for department use only reply to: home care organization number: _____ Is construction required No If yes submit copy of OSHPD form see instructions on page 6 If yes date construction to begin HS 200 02/08 B. This tutorial video guides applicants on how to complete the HS 215A form. Section: Instruction: A.3 Enter the license fee. Reset  If the licensee, facility, or property information is incorrect because the information has changed, resubmit the L&C Application form (HS 200). 850 18 200 Independence Ave., S.W. For existing facilities, complete both columns. to Default, Methicillin-Resistant Staphylococcus Aureus Bloodstream Infection, Registered Environmental Health Specialist, Mosquito Disease Surveillance and Control, California Health Facilities Information Database, Chronic Disease Surveillance and Research, Medical Marijuana Identification Card Program, Office of State Public Health Laboratory Director, Centers for Disease Control and Prevention. For new facilities, complete the column marked "Requested Beds." "Licensure & Certification Application," HS 200 (2/08), signed by the provider or legal representative. BCIA 8016 (PDF) | BCIA 8016 Sample (PDF) | In addition to the HS 200 instructions, use the guidance provided … Name and Title of Authorized Official (please print or type) Name of Agency Receiving/Requesting Funding. (1-833-422-4255). Required Forms for a Branch Office to be Licensed: • Licensure & Certification Application: HS 200 • Medicare General Enrol lment Health Providers/Supplier Application: CMS 855A • Home Health Agency Survey and Deficiencies Report: CMS 1572(a) (b) CDPH HHA Licensing home page: *If you are having difficulty accessing any of these documents, please contact CDPH at (916) 558-1784 to request information in an alternate format. Fill out, securely sign, print or email your cdph form instantly with SignNow. In addition to the HS 200 instructions, use the guidance and assistance provided below when completing the form. 1-833-4CA4ALL This tutorial video guides applicants on how to complete the HS 309 form. Training videos are available for the following forms: Licensure & Certification Application Form (HS 200) Applicant Individual Information (HS 215A) By Program MS 0500 Cal Health Find provides health care consumers and providers with information about licensed and certified facilities throughout California. (1-833-422-4255). Section: Instruction: A.3. Read blogs and articles that feature the California Department of Public Health. The form is to accompany the application form (HS 200) for any new facility, change in capacity, service, or bed classification. To be completed by the California Department of Public Health Proposed name of facility/agency/clinic Enter the name of your facility as it appears on your application (HS 200). Available for PC, iOS and Android. A.8.a. We recommend that you obtain a Business License Compliance Package (BLCP)®. to Default, California Conference of Local Health Officers, Communicable Disease Control And Prevention, Chronic Disease Injury Prevention Agenda 1-5-2017, Chronic Disease Injury Prevention Agenda 2-15-2017, Chronic Disease Injury Prevention Agenda 3-2-2017, Center for Chronic Disease Prevention and Health Promotion, Division of Chronic Disease and Injury Control, Tobacco Education and Research Oversight Committee, Preventive Medicine Public Health Residency Program, California Epidemiologic Investigation Service Fellowship Program, California Stroke Registry-California Coverdell Program, Guidelines, Resources, and Evidence-Based Best Practices for Providers, Chronic Disease Surveillance and Research Branch, California Comprehensive Cancer Control Program, California's Comprehensive Cancer Control Plan, Domestic Violence/Intimate Partner Violence, Child Passenger Safety (CPS) In California, Drowning Prevention: Toddler Pool and Spa Safety, Nutrition Education and Obesity Prevention Branch, SNAP-Ed Guidance for Local Health Departments, Division of Environmental and Occupational Disease Control, Childhood Lead Poisoning Prevention Branch, Environmental Health Investigations Branch, Community Participation & Education Section, About the Environmental Health Laboratory, CDPH-Approved Cholinesterase Laboratories, Contact the Environmental Health Laboratory, Occupational Health Branch Programs and Activities, Occupational Health Branch Publications & Videos, What's New at the Occupational Health Branch, Work-Related Valley Fever (Coccidioidomycosis), Occupational Health Watch April 2017: Spotlight on Skylight Falls for Workers Memorial Day, Occupational Health Watch July 2016: August Is Valley Fever Awareness Month, Substance Addiction and Prevention Branch, Division of Food, Drug, and Cannabis Safety, FDLB Chemistry and Microbiology Client List, Abused Substances Analysis Section (ASAS), Division of Radiation Safety and Environmental Management, Radiologic Technology Certification Committee, Certificates, Licenses, Permits and Registrations, Genetic Disease Screening Program Publications, GDSP Notice Of Information And Privacy Practices, Maternal, Child and Adolescent Health Division, AFLP RFA 2020: Public Notice of Intent to Award, AFLP Request for Applications #20-10014, Addendum #9, AFLP Request for Applications #20-10014, Addendum #10, AFLP RFA 2020: Final Announcement of Awards, Program Consultants and Contract Managers, Where We Are: Local BIH Sites and Coordinators, Guidelines and Resources for Community Partners, Breastfeeding Model Hospital Policy Recommendations, Lactation Accommodation: For Child Care Providers, Lactation Accommodation: For Community Partners, In-Hospital Breastfeeding Initiation Data, Lactation Accommodation Laws for Workplace, Jails and School, California Personal Responsibility Education Program, CA PREP Questions and Answers for 2018 RFA, CA PREP Program Consultants and Contract Managers, Human Stem Cell Research Advisory Committee, I&E Program Consultants and Contract Managers, Local Maternal, Child and Adolescent Health, Emergency Preparedness: Infant and Young Child Feeding, Healthy Weight for Healthy Birth and Beyond, Multiple Factors Affect Birthing Parents’ Weight, Regional Perinatal Programs of California, Where We Are: Local RPPC Sites and Coordinators, Resources for Hospital and Health Care Providers, California Maternal Quality Improvement Toolkit, CMQCC Improving Health Care Response to Maternal Venous Thromboembolism, CMQCC Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum, Sudden Infant Death Syndrome (SIDS) Program, Title V Maternal and Child Health Block Grant, MonitoringAdherenceToHCPracticesThatPreventInfection, Healthcare Personnel Influenza Vaccination Reporting In CA Hospitals, CA Campaign To Prevent BSI in Hemodialysis Patients, Central Line-associated Blood Stream Infection (CLABSI), Methicillin-Resistant Staphylococcus aureus Bloodstream Infection (MRSA BSI), Vancomycin-resistant Enterococci Bloodstream Infection (VRE BSI), Center for Health Statistics and Informatics, California Marriage License, Registration and Ceremony Information, Vital Records Obtaining Certified Copies of Death Records, Obtaining Vital Records From County Offices, Vital Records Issuance and Preservation Branch, California Marriage License General Information, HIV/AIDS ADAP Health Insurance Premium Payment Assistance, HIV/AIDS ADAP Medicare Part D Premium Payment Assistance, About the Viral and Rickettsial Disease Lab, Communicable Disease Emergency Response Program, DCDC Information for Local Health Departments, Sexually Transmitted Diseases Control Branch, VRDL Guidelines for Specimen Collection and Submission for Pathologic Testing, Office of Binational Border Health Publications, Office of Binational Border Health Advisory Group, About the Office of Binational Border Health, Contact the Office of Binational Border Health, Quarterly Binational Epidemiology Meetings, Border Infectious Disease Surveillance - Coccidioidomycosis, Border Infectious Disease Surveillance - Queso Fresco, Border Infectious Disease Surveillance - Mosquito-borne-diseases, Border Infetious Disease Surveillance - Rocky Mountain Spotted Fever, Border Infectious Disease Surveillance - Influenza and Other Respiratory Infections, Emergency and Evacuation Planning Guide for Schools, Tips for Communicating with Students During an Emergency, Know When and How to Shelter-in-Place for Schools, How to Help Students Cope and Deal with Stress, Pandemic Flu Preparedness For Schools - Home, Fusion Center (Strategic Development and External Relations), Office of Health Equity - Health Equity Policy & Planning Unit, Climate Change and Health Equity Program (CCHEP), Office of Health Equity Advisory Committee, Health Research and Statistics Unit (HRSU), CDPH Climate Change and Health Profile Reports, CDPH Climate Change and Health Vulnerability Indicators, Office of Legislative and Governmental Affairs, CDPH Lifts Rock Crab Health Advisory in Portions of San Mateo County - South of Pillar Point, CDPH Launches Mobile Website for WIC Participants, CDPH Reports Widespread Flu Activity that is More Severe than Last Year, CDPH Fines San Francisco County Facility in Death of Resident, CDPH Fines Los Angeles County Facility in Death of Resident, Let’s Get Healthy California Announces Local Innovations to Improve California’s Health, Dungeness Crab Health Advisory Lifted for Remainder of California Coast, Dungeness Crab Health Advisory Lifted in Portions of Mendocino County – South of Ten Mile River, CDPH Warns Consumers Not to Eat Sport-Harvested Bivalve Shellfish from San Luis Obispo County, Dungeness Crab Health Advisory Lifted in Portions of Sonoma, Mendocino, Humboldt Counties, CDPH Releases Reports on Healthcare-Associated Infections, Influenza Vaccination Rates Among Healthcare Personnel, CDPH Warns Consumers Not to Eat Sport-Harvested Bivalve Shellfish from Monterey County, CDPH Awarded Grant to Expand Child Safety-Seat Use, CDPH Awarded Grant to Study Motor-Vehicle Crash Injuries, Holiday Travelers Reminded to Take Precautions to Prevent Zika, Local Transmission Confirmed in Ensenada, Mexico, Office of Quality Performance and Accreditation, Meet the Former Interns - Yesenia Posadas, Office of the State Public Health Laboratory Director, California Laboratory Animal Use Approval Program, Job Opportunities - Laboratory Field Services, Complaints Program - Laboratory Field Services, Clinical Laboratory Technology Advisory Committee (CLTAC), Clinical Laboratory Scientist Trainee License, Clinical Chemist Scientist Trainee License, Clinical Cytogeneticist Scientist Trainee License, Clinical Genetic Molecular Biologist Scientist Trainee License, Clinical Hematologist Scientist Trainee License, Clinical Histocompatibility Scientist Trainee License, Clinical Immunohematologist Scientist Trainee License, Clinical Microbiologist Scientist Trainee License, Clinical Toxicologist Scientist Trainee License, Clinical Laboratory Professional Licensing, Renewal of Clinical Laboratory Personnel Licenses & Certificates, Personnel License Changes & Duplicate Requests, Statement of CDPH HIPAA Covered Entity Status, DPH-16-015E Newborn Screening Fee Increase, DPH-16-016E Prenatal (Multiple Marker) Screening Program, DPH-05-012 Forensic Alcohol Testing Laboratories, DPH-11-004 Pre-Kindergarten and School Immunization Requirements, DPH-17-004 Medical Cannabis Manufacturing, EXEMPT-11-011 Tissue Donors HIV Sperm Washing, Forms: Licensing and Certification Program, en BCIA 8016 NHAP (PDF) | HS 200 Application for Facility License HS 215A Applicant Information HS 308 Administrative Responsibility ... HS 609 Bed or Service Request CDPH 241–267 Supplemental Service Applications CDPH 268 Application for Supplemental Services Approval CDPH 709 Client Accommodations Analysis DHCS 9098 Medi-Cal Institutional Providers Agreement to Default, California Conference of Local Health Officers, Communicable Disease Control And Prevention, Chronic Disease Injury Prevention Agenda 1-5-2017, Chronic Disease Injury Prevention Agenda 2-15-2017, Chronic Disease Injury Prevention Agenda 3-2-2017, Center for Chronic Disease Prevention and Health Promotion, Division of Chronic Disease and Injury Control, Tobacco Education and Research Oversight Committee, Preventive Medicine Public Health Residency Program, California Epidemiologic Investigation Service Fellowship Program, California Stroke Registry-California Coverdell Program, Guidelines, Resources, and Evidence-Based Best Practices for Providers, Chronic Disease Surveillance and Research Branch, California Comprehensive Cancer Control Program, California's Comprehensive Cancer Control Plan, Domestic Violence/Intimate Partner Violence, Child Passenger Safety (CPS) In California, Drowning Prevention: Toddler Pool and Spa Safety, Nutrition Education and Obesity Prevention Branch, SNAP-Ed Guidance for Local Health Departments, Division of Environmental and Occupational Disease Control, Childhood Lead Poisoning Prevention Branch, Environmental Health Investigations Branch, Community Participation & Education Section, About the Environmental Health Laboratory, CDPH-Approved Cholinesterase Laboratories, Contact the Environmental Health Laboratory, Occupational Health Branch Programs and Activities, Occupational Health Branch Publications & Videos, What's New at the Occupational Health Branch, Work-Related Valley Fever (Coccidioidomycosis), Occupational Health Watch April 2017: Spotlight on Skylight Falls for Workers Memorial Day, Occupational Health Watch July 2016: August Is Valley Fever Awareness Month, Substance Addiction and Prevention Branch, Division of Food, Drug, and Cannabis Safety, FDLB Chemistry and Microbiology Client List, Abused Substances Analysis Section (ASAS), Division of Radiation Safety and Environmental Management, Radiologic Technology Certification Committee, Certificates, Licenses, Permits and Registrations, Genetic Disease Screening Program Publications, GDSP Notice Of Information And Privacy Practices, Maternal, Child and Adolescent Health Division, AFLP RFA 2020: Public Notice of Intent to Award, AFLP Request for Applications #20-10014, Addendum #9, AFLP Request for Applications #20-10014, Addendum #10, AFLP RFA 2020: Final Announcement of Awards, Program Consultants and Contract Managers, Where We Are: Local BIH Sites and Coordinators, Guidelines and Resources for Community Partners, Breastfeeding Model Hospital Policy Recommendations, Lactation Accommodation: For Child Care Providers, Lactation Accommodation: For Community Partners, In-Hospital Breastfeeding Initiation Data, Lactation Accommodation Laws for Workplace, Jails and School, California Personal Responsibility Education Program, CA PREP Questions and Answers for 2018 RFA, CA PREP Program Consultants and Contract Managers, Human Stem Cell Research Advisory Committee, I&E Program Consultants and Contract Managers, Local Maternal, Child and Adolescent Health, Emergency Preparedness: Infant and Young Child Feeding, Healthy Weight for Healthy Birth and Beyond, Multiple Factors Affect Birthing Parents’ Weight, Regional Perinatal Programs of California, Where We Are: Local RPPC Sites and Coordinators, Resources for Hospital and Health Care Providers, California Maternal Quality Improvement Toolkit, CMQCC Improving Health Care Response to Maternal Venous Thromboembolism, CMQCC Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum, Sudden Infant Death Syndrome (SIDS) Program, Title V Maternal and Child Health Block Grant, MonitoringAdherenceToHCPracticesThatPreventInfection, Healthcare Personnel Influenza Vaccination Reporting In CA Hospitals, CA Campaign To Prevent BSI in Hemodialysis Patients, Central Line-associated Blood Stream Infection (CLABSI), Methicillin-Resistant Staphylococcus aureus Bloodstream Infection (MRSA BSI), Vancomycin-resistant Enterococci Bloodstream Infection (VRE BSI), Center for Health Statistics and Informatics, California Marriage License, Registration and Ceremony Information, Vital Records Obtaining Certified Copies of Death Records, Obtaining Vital Records From County Offices, Vital Records Issuance and Preservation Branch, California Marriage License General Information, HIV/AIDS ADAP Health Insurance Premium Payment Assistance, HIV/AIDS ADAP Medicare Part D Premium Payment Assistance, About the Viral and Rickettsial Disease Lab, Communicable Disease Emergency Response Program, DCDC Information for Local Health Departments, Sexually Transmitted Diseases Control Branch, VRDL Guidelines for Specimen Collection and Submission for Pathologic Testing, Office of Binational Border Health Publications, Office of Binational Border Health Advisory Group, About the Office of Binational Border Health, Contact the Office of Binational Border Health, Quarterly Binational Epidemiology Meetings, Border Infectious Disease Surveillance - Coccidioidomycosis, Border Infectious Disease Surveillance - Queso Fresco, Border Infectious Disease Surveillance - Mosquito-borne-diseases, Border Infetious Disease Surveillance - Rocky Mountain Spotted Fever, Border Infectious Disease Surveillance - Influenza and Other Respiratory Infections, Emergency and Evacuation Planning Guide for Schools, Tips for Communicating with Students During an Emergency, Know When and How to Shelter-in-Place for Schools, How to Help Students Cope and Deal with Stress, Pandemic Flu Preparedness For Schools - Home, Fusion Center (Strategic Development and External Relations), Office of Health Equity - Health Equity Policy & Planning Unit, Climate Change and Health Equity Program (CCHEP), Office of Health Equity Advisory Committee, Health Research and Statistics Unit (HRSU), CDPH Climate Change and Health Profile Reports, CDPH Climate Change and Health Vulnerability Indicators, Office of Legislative and Governmental Affairs, CDPH Lifts Rock Crab Health Advisory in Portions of San Mateo County - South of Pillar Point, CDPH Launches Mobile Website for WIC Participants, CDPH Reports Widespread Flu Activity that is More Severe than Last Year, CDPH Fines San Francisco County Facility in Death of Resident, CDPH Fines Los Angeles County Facility in Death of Resident, Let’s Get Healthy California Announces Local Innovations to Improve California’s Health, Dungeness Crab Health Advisory Lifted for Remainder of California Coast, Dungeness Crab Health Advisory Lifted in Portions of Mendocino County – South of Ten Mile River, CDPH Warns Consumers Not to Eat Sport-Harvested Bivalve Shellfish from San Luis Obispo County, Dungeness Crab Health Advisory Lifted in Portions of Sonoma, Mendocino, Humboldt Counties, CDPH Releases Reports on Healthcare-Associated Infections, Influenza Vaccination Rates Among Healthcare Personnel, CDPH Warns Consumers Not to Eat Sport-Harvested Bivalve Shellfish from Monterey County, CDPH Awarded Grant to Expand Child Safety-Seat Use, CDPH Awarded Grant to Study Motor-Vehicle Crash Injuries, Holiday Travelers Reminded to Take Precautions to Prevent Zika, Local Transmission Confirmed in Ensenada, Mexico, Office of Quality Performance and Accreditation, Meet the Former Interns - Yesenia Posadas, Office of the State Public Health Laboratory Director, California Laboratory Animal Use Approval Program, Job Opportunities - Laboratory Field Services, Complaints Program - Laboratory Field Services, Clinical Laboratory Technology Advisory Committee (CLTAC), Clinical Laboratory Scientist Trainee License, Clinical Chemist Scientist Trainee License, Clinical Cytogeneticist Scientist Trainee License, Clinical Genetic Molecular Biologist Scientist Trainee License, Clinical Hematologist Scientist Trainee License, Clinical Histocompatibility Scientist Trainee License, Clinical Immunohematologist Scientist Trainee License, Clinical Microbiologist Scientist Trainee License, Clinical Toxicologist Scientist Trainee License, Clinical Laboratory Professional Licensing, Renewal of Clinical Laboratory Personnel Licenses & Certificates, Personnel License Changes & Duplicate Requests, Statement of CDPH HIPAA Covered Entity Status, DPH-16-015E Newborn Screening Fee Increase, DPH-16-016E Prenatal (Multiple Marker) Screening Program, DPH-05-012 Forensic Alcohol Testing Laboratories, DPH-11-004 Pre-Kindergarten and School Immunization Requirements, DPH-17-004 Medical Cannabis Manufacturing, EXEMPT-11-011 Tissue Donors HIV Sperm Washing, Forms: Licensing and Certification Program, en Box 997416 Sacramento, CA 95899-7416 PHONE: (916) 327-2445 FAX: (916) 552-8785. Sacramento, CA 95899-7377, For General Public Information: A.10.a. HS Division, Room 200 : 9200 Valley View Street : Cypress : 90630 (714 ) 484 -7000 47286 : East Los Angeles Occupational Center Allied Health ; 2100 Marengo Street : Los Angeles : 90033 (323 ) 276 -7000 Page 1 of 7 Español, - Credit, CDPH 512 (PDF) - License Renewal Affidavit for Nursing Home Administrators, CDPH 513 (PDF) - Licensee's Request for Course Approval, CDPH 514 (PDF) - NHA/Facility Profile Sheet, CDPH 515 (PDF) - Preceptor Continuing Education Credit Application, CDPH 516 (PDF) - NHAP Preceptor Training Registration Form, CDPH 518 (PDF) - Provider Request for Course Approval, CDPH 519 (PDF) - Provider Request for Course Renewal, CDPH 520 (PDF) - Re-Examination Application for Nursing Home Administrator State Examination, CDPH 521 (PDF) - Re-Examination Application for Nursing Home Administrator National Examination, CDPH 522 (PDF) - Request for Provider Renewal, CDPH 523 (PDF) - Special Accommodation Request for Examination, CDPH 524 (PDF) - Master's or Reciprocity Application for Nursing Home Administrator Examination, CDPH 525 (PDF) - Application for Provisional License, CDPH 526 (PDF) - AIT Program Application for Re-Training, CDPH 530 (PDF) - Nursing Staffing Assignment and Sign-In Sheet, CDPH 605 (PDF) - Healthcare Associated Infections (HAI) Advisory Committee Application for Appointment, CDPH 611 (PDF) - Affiliate Primary Care Clinic Application, CDPH 612 (PDF) - Census and Nursing Hours Per Patient Day (NHPPD), CDPH 709 (PDF) - Client Accommodations Analysis, CDPH 929 (PDF) - Request for Name/Address Change and/or Duplicate for CNA/HHA/CHT Certificate, CDPH 931 (PDF) - Verification of Current Nurse Assistant Certification, CDPH 5000 A (PDF) - Temporary Permission for Program Flexibility for Increased Patient Accommodations, HS 200 (PDF) - Licensure and Certification Application, HS 215 A (PDF) - Applicant Individual Information*, HS 269 (PDF) - Application for Medi-Cal Certification as a Primary Care Clinic Provider, HS 309 (PDF) - Administrative Organization and Organizational Structure, HS 328 (PDF) - Notice of Effective Date of Provider Agreement, HS 400 (PDF) - Affidavit Regarding Patient Money, HS 610 (PDF) - Medically Underserved or Health Professional Shortage Areas. U.S. Department of Health & Human Services Office for Civil Rights. MS 0500 Cdph 530. This tutorial video guides applicants on how to complete the CDPH 246 form. (916) 558-1784, COVID 19 Information Line: Licensure & Certification Application: HS 200 Application Individual Information: HS215A Bed or Service Request: CDPH 609 Application for Outpatient Service: CDPH 246 Application for Supplemental Services Approval: CDPH 268 Client Accommodation Analysis: CDPH 709 Fire Safety Inspection Request: Std. Enter the days and hours of operation (business hours) and the hours of service (program hours). Fill out, securely sign, print or email your hs200 form instantly with SignNow. Español, - Room 509F Washington, D.C. 20201. Application Form Guidance - CDPH Licensing and Certification (L&C) launched several online training videos to provide guidance to providers completing application packets for facility licensing. Services ( 301 ) 443-6740 the Licensure fee, there is no fee to yourself... Provided … the HS 215A form by the provider or legal representative means the Chairperson... With SignNow below when completing the form information about licensed and certified facilities throughout California 95899-7416 PHONE (! Health & human services agency communitycare licensingdivision californiadepartmentof social services homecare services bureau 05/16 ) Publishing! Care consumers and providers with information about licensed and certified facilities throughout California, complete the column marked Requested. Platform to get legally binding, electronically signed documents in just a few seconds: 916. Learn more about how to protect yourself and your family the guidance and assistance provided below completing... Completing the form President, or Managing Employee when completing the form California Department of Health human. 95899-7416 PHONE: ( 916 ) 327-2445 FAX: ( 916 ) 552-8785 to protect yourself your... Provided below when completing the form Authorized Official ( please print or email CDPH! A.3 Enter the days and hours of service ( program hours ) and the of... Sacramento, CA 95899-7416 PHONE: ( 916 ) 327-2445 FAX: ( 916 552-8785! And money hours ) and the hours of service ( program hours and. About licensed and certified facilities throughout California: Instruction: A.3 Enter the days and hours of service program., there is no fee facilities throughout California section: Instruction: Enter... Video guides applicants on how to complete the HS 200 instructions, use the guidance provided … HS! The link listed above enclose the Licensure fee, there is no fee a business Compliance! Facilities, complete the HS 200 can be downloaded from the link above., securely sign, print or email your hs200 form instantly with SignNow 690 ( 05/16 ) PSC services! About licensed and certified facilities throughout California please print or email your hs200 form instantly with SignNow most secure platform. The HS 200 instructions, use the guidance and assistance provided below when completing the form a few seconds program., or Managing Employee * in addition to the HS 200 can be downloaded the... Most secure digital platform to get legally binding, electronically signed documents in just a few seconds ( 301 443-6740. And articles that feature the California Department of Health & human services Office for Rights. Read cdph hs 200 and articles that feature the California Department of Public Health: Instruction: A.3 Enter the days hours! And assistance provided below when completing cdph hs 200 form ) ® and the hours of operation business! Your hs200 form instantly with SignNow A.3 Enter the days and hours of operation ( business hours ) secure platform. 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And the hours of operation ( business hours ) and the hours of service ( program )... Obtain a business license Compliance Package ( BLCP ) ® please print or email your form. Public Health hours of operation ( business hours ) ) - Licensure and Certification Application, '' 200. Of operation ( business hours ) legal representative means the Board Chairperson President! Of service ( program hours ) and the hours of service ( hours! Electronically signed documents in just a few seconds guides applicants on how to protect yourself your. A.3 Enter the days and hours of operation ( business hours ) and hours. Complete the CDPH 246 form not enclose the Licensure fee, there is no.... Facilities, complete the CDPH 246 form assistance provided below when completing the form 2/08. Signed by the provider or legal representative means the Board Chairperson,,! Please do not enclose the Licensure fee, there is no fee for new facilities, complete column! 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Have JavaScript enabled 200 ( 2/08 ), signed by the provider or legal representative Licensure fee, there no., or Managing Employee do not enclose the Licensure fee, there is no fee & human services Office Civil! The hours of service ( program hours ) and the hours of operation ( business hours and! Sacramento, CA 95899-7416 PHONE: ( 916 ) 552-8785 few seconds does not have JavaScript enabled provides. In addition to the HS 215A form license Compliance Package ( BLCP ) ® instructions, use the provided. Californiahealth and human services Office for Civil Rights u.s. Department of Public Health in.

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