Hs 200 2026

The document is an application form from the California Department of Public Health for licensure and certification of health facilities, agencies, or clinics. It outlines the necessary information required for initial applications, changes of ownership, and management agreements. Key sections include application details, licensee information, facility specifics, property ownership, and management company data. The form emphasizes compliance with local ordinances and health regulations while collecting essential data to assess the applicant's capability to provide health services.

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Begin with Section A, APPLICATION INFORMATION. Select the type of application by checking one of the options: Initial, Change of Ownership, Management Company, or Other Change.
For Change of Ownership applications, provide the effective date of ownership change in item 2. Enter the amount of fee enclosed in item 3.
In item 4, check all applicable types of changes and specify the type of facility in item 5 by selecting from the provided options.
Proceed to Section B for LICENSEE INFORMATION. Fill in your licensee name and federal employer’s tax ID number. Ensure that all contact details are accurate.
Complete Section C with FACILITY, AGENCY OR CLINIC INFORMATION. Provide details about management agreements if applicable and ensure all required attachments are included.
Finally, review all sections for accuracy before submitting your application through our platform.

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