Hs 215a See full list on cpca. Try Now! All Facilities Letter (AFL) Summary This AFL announces that the California Department of Public Health (CDPH) has revised Licensure and Certification Application (HS 200) (PDF) and Applicant Individual Information (HS 215A) (PDF) forms. HS 215A is a form for individuals who own or operate health or community care facilities in California. www. To better accomplish this mission and implement a standardized process, CAB has absorbed all health care facility and agency applications previously processed by the Center’s district offices. 5MB) HS 215 A - Applicant Individual Information* (PDF) HS 269 - Application for Medi-Cal Certification as a Primary Care Clinic Provider (PDF) HS 309 - Administrative Organization and Organizational Structure (PDF) HS 328 - Notice of Effective Date of Provider Agreement (PDF) Jul 1, 2023 · This AFL announces that the California Department of Public Health (CDPH) has revised Licensure and Certification Application (HS 200) (PDF) and Applicant Individual Information (HS 215A) (PDF) forms. Form Hs215a Is Often Used In California Department Of Public Health, California Legal Forms, Legal And United States Legal Forms. Why does CAB require a CDPH 270 be signed by a California licensed architect or local building authority? Application Packet Forms HS 200 - Licensure and Certification Application (PDF, 1. This HS 215A form needs to be completed as part of an application package plus it needs to be completed for disclosure purposes when changes are reported in officers, directors, purchase of stock, etc. 5MB) HS 215A - Applicant Individual Information (PDF) HS 309 - Administrative Organization and Organizational Structure (PDF) CDPH 322 - Transmittal Application for Criminal Background Investigation (PDF) CDPH 325 - Criminal Record Clearance Submissions (PDF) Centralized Applications Branch The Centralized Applications Branch (CAB) mission is to ensure standardization and consistency of the state licensing and federal certification application process. Please begin using the revised form effective immediately. The revised forms will be e ective July 1, 2023. 5MB) HS 215A - Applicant Individual Information (PDF) HS 309 - Administrative Organization and Organizational Structure (PDF) HS 400 - Affidavit Regarding Patient Money (PDF) HS 402 - Surety Bond Verification (PDF) HS 602 - Transfer Agreement (PDF) In addition to the HS 215A instructions found on the CDPH website, use the guidance and assistance provided below when completing the form. In addition to the HS 215A instructions available on the CDPH website, please follow the guidance provided below when completing the form. Meet California Department of Public Health (CDPH), Licensing and Certification Program, requirement to submit form HS 215A by June 30, 2022. FormsWorkflow. The HS215A form also requires information regarding criminal history, facility/clinic involvement, and adverse actions. . Fill Out The Applicant Individual Information - California Online And Print It Out For Free. Home Health Agency Initial and Change of Ownership Application Checklist The following is a list of application forms and supporting documents required for a complete application packet. Jan 19, 2023 · *All Facilities Letters are listed in ascending order by release date, with updated AFLs listed directly after their original version This tutorial video guides applicants on how to complete the HS 215A form. 4. It serves as a means for individuals to provide essential information regarding their health status, which may be required by various state agencies. Jul 1, 2023 · Download Fillable Form Hs215a In Pdf - The Latest Version Applicable For 2025. CAB 3 days ago · A skilled nursing facility shall notify the department of any changes in its medical director by submitting an HS 215A form or its successor form, a résumé, and proof of certification or progress toward certification for its medical director within 10 calendar days of those changes. It requires personal information, criminal record disclosure, professional licenses, employment history, and details about involvement with other facilities. This form is intended for any individual owning the applicant facility or for any individual involved (now or in the past) with any health or community care facility. Can I submit aged HS 215As with my application submissions? The signature and date of the HS 215A form should be within the last three months and must contain the signature of the individual whom the form is regarding. It serves to gather essential information about the applicant's qualifications and any past involvement in health-related fields. An application packet is required for any of the following: Initial (new) facility or agency Change of Ownership Report of Change CAB processes applications in the order in which they HS 215A - APPLICANT INDIVIDUAL INFORMATION. Intermediate Care Facility/Developmentally Disabled-Nursing (ICF/DD-N) ICF/DD-Continuous Nursing (ICF/DD-CN) Initial and Change of Ownership Application Checklist The following is a list of application forms and supporting documents required for a complete application packet. 7/2023). Facility Administrator and Medical Director should collaboratively complete CDPH Form HS 215A; the facility is responsible for submitting the required documents to CDPH. Oct 13, 2021 · For this report a SNF must submit an HS 215A, resume, and proof of certification or progress toward certification to CDPH. It contains personal and professional information, criminal record, employment history, and other details required for licensing and certification. Section: B. Save or instantly send your ready documents. Download Applicant Individual Information (HS 215 A) – Department of Public Health (California) form DHCS 9098 (07/2025) – Medi-Cal Provider Agreement HS 200 (07/2023) – Licensure and Certification Application HS 215A (07/2023) – Applicant Individual Information HS 309 (10/2011) – Administrative Organization CDA IMS 33 (11/2023) – Balance Sheet CDA IMS 35 (02/2024) – Cash Flow Forecast The California Department of Health Services (CDHS), Licensing and Certification (L&C) Program has revised and updated the Applicant Individual Information HS 215A (7/06) form. The form aims to assess the Jul 17, 2023 · The California Department of Public Health recently released new All Facilities Letters (AFL) on licensing and certification applications and fiscal year 2023-24 health care facility license schedule. An HS 215A form (PDF) or its successor form A résumé Whether its medical director is certified as a Certified Medical Director according to the requirements established by the American Board of Post-Acute and Long-Term Care Medicine or an equivalent organization as determined by CDPH The HS 215A form is a document required by the California Department of Public Health for individuals involved in owning or operating health facilities or community care facilities. Complete CA HS 215A 2008-2025 online with US Legal Forms. The document is a form (HS 215A) from the California Department of Public Health, Licensing and Certification, intended for individuals applying for a license to operate health or community care facilities. Initial Application Checklist The following is a list of application forms and supporting documents required for a complete application packet. The HS 215A form is a crucial document for individuals associated with owning or operating health and community care facilities in California, ensuring compliance with the state's Department of Public Health Licensing and Certification requirements. Easily fill out PDF blank, edit, and sign them. 5MB) HS 215A - Applicant Individual Information (PDF) HS 309 - Administrative Organization and Organizational Structure (PDF) CDPH 322 - Transmittal Application for Criminal Background Investigation (PDF) CDPH 325 - Criminal Record Clearance Submissions (PDF) HS 200 - Licensure and Certification Application (PDF, 1. “Applicant Individual Information,” Form HS 215A (Rev. It collects personal, criminal, professional, and business information, as well as disclosure of any adverse actions or affiliations with other facilities. 5. Jun 15, 2022 · Forms/Documents 10. com State of California ­ Health and Human Services Agency California Department of Public Health Licensing and Certification FACILITY INFORMATION SHEET You are required to complete the following for each facility (including all facilities in all business entities) with which you have Home Health Agency Change of Director of Patient Care Services Application Packet A State license is required to operate as a Home Health Agency (HHA) in California. Failure to include each of the forms and documents will delay processing and may result in denial of the application. Health Care Facilities Paper Application Packet The Centralized Applications Branch (CAB) is primarily responsible for processing licensing and certification applications for health care facilities and providers. G. Each person having five (5) percent or more (direct or indirect) ownership interest and/or control interest in the applicant facility. Each management personnel must submit an Applicant Individual Information - HS 215A form, a resume, and a list of hospice agencies that the individual is currently serving as management personnel. Application Packet Forms HS 200 - Licensure and Certification Application (PDF, 1. An HHA means “a private or public organization, including but not limited to, any partnership, corporation, political subdivision of the state, or other government agency within the state, which provides, or arranges for the Skilled Nursing Facility (SNF) Change of Ownership (CHOW) Application Checklist The following is a list of application forms and supporting documents required for a complete application packet. 07/23), signed and dated by: I. CDPH HS215A is a form for individuals who have ownership or control interest in health care facilities, agencies, or clinics in California. 11. The HS 215A form may be obtained from the L&C/CDHS Centralized Applications Unit (CAU) website. In addition to the Form HS 215A instructions found on the CDPH website, use the guidance provided below when completing the form. Form HS 215A serves as a crucial component of the application process for state healthcare facility licensing and federal certification. DPCS designee, and medical director or contracted medical director For each of these individuals, a hospice agency must submit to CDPH: form HS 215A (or successor form), resumé, and list of all hospice agencies that the individual is currently serving as management personnel steopathic Association, or an equivalen Fill CA HS 215A instantly, Edit online. Forms/Documents 11. Sign, fax and printable from PC, iPad, tablet or mobile. Can I submit aged HS 215As with my application submissions? The date of the HS 215A form should be within the last three months. B. HS 200 - Licensure and Certification Application ( PDF, 1. org What is the HS 215A? The HS 215A form, also known as the HS 215A application, is a document used primarily in California for health-related purposes. It is mandatory for individuals holding more than five percent ownership or key positions within these establishments. HS 215A (2/08) 2 American LegalNet, Inc. Failure to include each of the forms and documents will delay processing. Applicant Individual Information, HS 215A (Rev. Initial and Change of Ownership Application Checklist The following is a list of application forms and supporting documents required for a complete application packet. , as required by law, even though no change in legal ownership is occurring. Section: Instructions: Meet California Department of Public Health (CDPH), Licensing and Certification Program, requirement to submit form HS 215A. 0umjl4g onsp 3tu azl4 zjunj1 k5vevn swv rt 887 xtp