Cdph Hs 215a Form

Cdph Hs 215a Form - BLANK HS 215A APPLICANT INDIVIDUAL INFORMATION This form must be completed for the following individuals and include original signatures Administrator of the facility and Administrator Designee Owners directors board members corporate officers LLC members managers and partners of the applicant organization and or Management

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

Cdph Hs 215a Form

Cdph Hs 215a Form

HS 215A • APPLICANT INDIVIDUAL INFORMATION [CCR section 74661 (a)(5) & 74665HSC section1728] This form must be completed and signed for the following individuals: Administrator, Administrator Designee and the Director of Patient Care Services of the facility • Owners, directors, board members, corporate officers,

HS 215A Applicant Individual Information FOR DEPARTMENTAL USE ONLY District ELMS Facility Number Proposed name of facility agency clinic APPLICANT INDIVIDUAL INFORMATION 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

Forms Licensing And Certification Program California

For visual instructional assistance on how to complete specific application forms please visit the following links Licensure Certification Application Form HS 200 Applicant Individual Information HS 215A Application for Medi Cal Certification as a Primary Care Clinic Provider HS 269 Administrative Organization Form HS 309

Cdph Service Form Fill Online Printable Fillable Blank PdfFiller

HS 200 07 2023 Licensure and Certification Application HS 215A 07 2023 Applicant Individual Information HS 309 10 2011 Administrative Organization

ICFDD N ICFDD CN Initial Chow Provider Checklist CDPH

All free standing SNFs are required to report the name and certification status of their medical director to CDPH no later than June 30 2022 For this report a SNF must submit an HS 215A resume and proof of certification or

Form Cdph 183 Fill Out Printable PDF Forms Online

Applicant Individual Information Form HS 215A Rev 7 2023 In addition to the Form HS 215A instructions found on the CDPH website use the guidance provided below when completing the form Section Instruction B 4 Provide your Driver s License Number If not available provide a State Issued Identification Card Number B 5

Blank HS 215A . APPLICANT INDIVIDUAL INFORMATION [HSC section 1339, (Standards of Quality Hospice Care (SQHC), 2003, section 5.1 - 5.3, and 6.1)] This form must be completed for the following individuals and include original signatures: • Administrator, Administrator Designee, Director of Patient Care Services, Director of Patient Care Services

HHA Initial CHOW Application Checklist CDPH Home

HS 215A 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 Please begin using the revised form e ective immediately

Cdph Hs 215a Form

Applicant Individual Information Form HS 215A Rev 7 2023 In addition to the Form HS 215A instructions found on the CDPH website use the guidance provided below when completing the form Section Instruction B 4 Provide your Driver s License Number If not available provide a State Issued Identification Card Number B 5

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

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