State of California--Health and Welfare Agency - Department 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out your Provider Number (License/Certification Number) and Legal Entity Name. Ensure that all fields are completed accurately to avoid delays.
3. Provide your Mailing Address, including City, State, and Zip Code. This information is crucial for correspondence regarding your application.
4. Complete the Facility Name and Facility Address sections. Include the relevant contact details such as Phone, Website, Fax, and Email.
5. Indicate the Type of Organization by selecting one of the options provided (e.g., Profit Corporation, Nonprofit Corporation).
6. Detail the TYPE OF SERVICE(S) PROVIDED and TARGET POPULATION. Be specific about the services offered to ensure compliance with certification standards.
7. For Residential Facilities only, complete the additional items required section, including Treatment/Recovery Capacity and attach necessary documentation.
8. Finally, review all entries for accuracy before signing. Ensure that authorized representatives sign in blue ink as required.

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