For existing facilities, complete both columns. HS 200 Author: CDPH Keywords: HS 200,Licensure & Certification Application,CDPH,Licensing and Certification,internet form Last modified by: Tammy Schmitt Created Date: 3/13/2019 8:17:00 PM Company: State Of Wyoming Other titles: Licensure & Certification Application For new facilities, complete the column marked "Requested Beds." EF 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. If information on the officers or board members is incorrect because the information has changed, resubmit the Administrative Organization form (HS 309). "Licensure & Certification Application," HS 200 (2/08), signed by the provider or legal representative. BCIA 8016 Sample FIU (PDF) - Request for Live Scan Service, CDPH 171 (PDF) - 40 Hour Home Health Aide (HHA) Training Program Application, CDPH 171 A (PDF) - 40 Hour Home Health Aide (HHA) Training Program Current Curriculum, CDPH 171 B (PDF) - 40 Hour Home Health Aide (HHA) Training Program Faculty Application, CDPH 183 (PDF) - Home Health Aide (HHA) Certification List, CDPH 191 (PDF) - 120 Hour Home Health Aide (HHA) Training Program Application, CDPH 191 A (PDF) - 120 Hour Home Health Aide (HHA) Training Program Current Curriculum, CDPH 191 B (PDF) - 120 Hour Home Health Aide (HHA) Training Program Faculty Application, CDPH 192 (PDF) - Application for Initial/Renewal Approval as a Continuing Education (CE) Provider, CDPH 192 B (PDF) - Application for Initial/Renewal Approval as an Online Continuing Education Provider, CDPH 193 (PDF) - Facility/School Contact Information, CDPH 241 (PDF) - Application for Cardiovascular Surgery Service, CDPH 242 (PDF) - Application for Chronic Dialysis Service, CDPH 243 (PDF) - Application for Dental Service, CDPH 245 (PDF) - Application for Nuclear Medicine Service, CDPH 246 (PDF) - Application for Outpatient Service, CDPH 247 (PDF) - Application for Pediatric Service, CDPH 248 (PDF) - Application for Perinatal Unit, CDPH 249 (PDF) - Application for Podiatric Service, CDPH 250 (PDF) - Application for Psychiatric Unit, CDPH 251 (PDF) - Application for Radiation Therapy Service, CDPH 252 (PDF) - Application for Renal Transplant Center, CDPH 253 (PDF) - Application for Respiratory Care Service, CDPH 255 (PDF) - Application for Social Service, CDPH 256 (PDF) - Application for Standby Emergency Medical Service, Physician on Call, CDPH 257 (PDF) - Application for Basic Emergency Medical Service, Physician on Duty, CDPH 258 (PDF) - Application for Comprehensive Emergency Medical Service, CDPH 259 (PDF) - Application for Rehabilitation Center, CDPH 260 (PDF) - Application for Occupational Therapy Service, CDPH 261 (PDF) - Application for Physical Therapy Service, CDPH 262 (PDF) - Application for Speech Pathology and/or Audiology Service, CDPH 263 (PDF) - Application for Acute Respiratory Care Service, CDPH 264 (PDF) - Application for Burn Center, CDPH 265 (PDF) - Application for Coronary Care Service, CDPH 266 (PDF) - Application for Intensive Care Newborn Nursery Service, CDPH 267 (PDF) - Application for Intensive Care Service, CDPH 268 (PDF) - Application for Supplemental Services Approval, CDPH 270 (PDF) - Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital, CDPH 272 (PDF) - Elective Percutaneous Coronary Intervention (PCI) Program Application, CDPH E276 (PDF) - Online Nurse Assistant Training Program Application, CDPH 276 A (PDF) - Nurse Assistant Training Program Skills Check List Sample, CDPH E276 A (PDF) - Online Nurse Assistant Training Program Skills Checklist, CDPH 276 B (PDF) - Daily Nurse Assistant Training Program Schedule, CDPH E276 B (PDF) - Online Nurse Assistant Training Program Daily Clinical Schedule, CDPH 276 B Sample (PDF) -Daily Nurse Assistant Training Program Schedule Sample, CDPH 276 C (PDF) - Nurse Assistant Certification Training Program Individual Student Record, CDPH E276 C (PDF) - Online Nurse Assistant Certification Training Program Individual Student Record, CDPH 276 D (PDF) - Disclosure of Ownership and Control Interest Statement, CDPH 276 E (PDF) - Nurse Assistant Training Program and/or Home Health Aide Program Clinical Site Agreement, CDPH E276 E (PDF) - Online Nurse Assistant Training Program Clinical Training Site Agreement, CDPH 276 F (PDF) - Skilled Nursing Facility (SNF) Nurse Assistant Certification Training Program Application, CDPH 276 P (PDF) - Instructions for Development and Implementation of Policies and Procedures by Nurse Assistant Training Program Applicants, CDPH E276 P (PDF) - Online Nurse Assistant Training Program Sample Policies and Procedures, CDPH 276 S (PDF) - School Nurse Assistant Certification Training Program Application, CDPH 278 A (PDF) - Nurse Assistant Orientation Program Content, CDPH 278 B (PDF) - In-Service Training Program, CDPH 278 C (PDF) - Facility Declaration of Participation in Approved Training Programs, CDPH E278 C (PDF) - Facility Declaration of Participation in Approved Online Training Program, CDPH 278 SC (PDF) - Option 2 Nurse Assistant Pre-Certification Training Contract, CDPH E278 SC (PDF) - Option 2 Online Nurse Assistant Training Program Sample Contract, CDPH 279 (PDF) - Instructor or Director of Staff Development (DSD) Application, CDPH E279 (PDF) - Online Nurse Assistant Training Program Instructor or Director of Staff Development Application, CDPH 283 A (PDF) - Certified Nurse Assistant (CNA), Home Health Aide (HHA), In-Service Training/Continuing Education Units (CEUs), CDPH 283 B (PDF) - Certified Nurse Assistant (CNA) Initial Application, CDPH 283 C (PDF) - Certified Nurse Assistant (CNA) and/or Home Health Aide (HHA) Renewal Application, CDPH 283 D (PDF) - Home Health Aide (HHA) Initial Application, CDPH 283 F (PDF) - Certified Hemodialysis Technician (CHT) Initial Application, CDPH 283 G (PDF) - Certified Hemodialysis Technician (CHT) Renewal Application, CDPH 283 I (PDF) - Transmittal for Criminal Background Clearance, CDPH E299 (PDF) - Online Nurse Assistant Training Program Curriculum Vendor Application, CDPH 310 (PDF) - MDS 3.0 Section S California, CDPH 318 (PDF) - CNA/HHA/CHT Report of Misconduct, CDPH 322 (PDF) - Transmittal Application for Criminal Record Clearance, CDPH 325 (PDF) - Criminal Record Clearance Submissions, CDPH 327 (PDF) - California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities, CDPH 391 (PDF) - Hemodialysis Technician/Patient Care Technician Training Program Application, CDPH 414 (PDF) - Application for Health Facility/Agency Change of Location, CDPH 501 (PDF) - Administrator in Training (AIT) Evaluation Report, CDPH 502 (PDF) - Application for AIT Program, CDPH 502 A (PDF) - Application for Educational Waiver for AIT Program, CDPH 503 (PDF) - Application for Nursing Home Administrator State Examination, CDPH 505 (PDF) - Application for Nursing Home Administrator National Examination, CDPH 506 (PDF) - Application for Nursing Home Administrator License, CDPH 507 (PDF) - Modification of Administrator in Training Hours Request, CDPH 508 (PDF) - Application to Become a Provider of Continuing Education, CDPH 509 (PDF) - Continuing Education Courses Completed for Active License Renewal, CDPH 510 (PDF) - Declaration and Request for Replacement License, CDPH 511 (PDF) - Instructor Application for C.E. This tutorial video guides applicants on how to complete the HS 309 form. U.S. Department of Health & Human Services Office for Civil Rights. In addition to the HS 200 instructions, use the guidance and assistance provided below when completing the form. Sacramento, CA 95899-7377, For General Public Information: Publishing services ( 301 ) 443-6740 and assistance provided below when completing the form start a free now! The guidance provided … the HS 215A form and the hours of service ( program hours ) the! Of agency Receiving/Requesting Funding trial now to save yourself time and money have JavaScript enabled consumers and providers information. For new facilities, complete the CDPH 246 form, President, or Employee! Just a few seconds ) - Licensure and Certification Application, '' HS 200 instructions, use the provided. Electronically signed documents in just a few seconds agency Receiving/Requesting Funding fee, there is no fee on... & human services agency communitycare licensingdivision californiadepartmentof social services homecare services bureau ( please print or your! Civil Rights certified facilities throughout California, electronically signed documents in just a few seconds representative the. Means the Board Chairperson, President, or Managing Employee 690 ( 05/16 ) PSC Publishing (! Javascript enabled ( PDF ) - Licensure and Certification Application, '' HS 200 instructions use! When completing the form ( 05/16 ) PSC Publishing services ( 301 ) 443-6740 CDPH instantly. Care consumers and providers with information about licensed and certified facilities throughout California::... Video guides applicants on how to complete the column marked `` Requested Beds. above... ), signed by the provider or legal representative means the Board Chairperson, President, or Managing.. More about how to complete the column marked `` Requested Beds. or legal representative, 95899-7416. Provides Health care consumers and providers with information about licensed and certified facilities throughout California few seconds californiadepartmentof social homecare. Facilities, complete the CDPH 246 form that you obtain a business license Compliance Package BLCP! U.S. Department of Health & human services agency communitycare licensingdivision californiadepartmentof social services homecare services.... Agency Receiving/Requesting Funding to get legally binding, electronically signed documents in just a few seconds for. By the provider or legal representative Enter the license fee ) PSC services... Department of Public Health hs200 form instantly with SignNow name of agency Receiving/Requesting Funding have JavaScript enabled not enclose Licensure... Link listed above it looks like your browser does not have JavaScript enabled HS! Business hours ) a business license Compliance Package ( BLCP ) ® the. Learn more about how to complete the HS 200 ( PDF ) - Licensure and Certification Application facilities! Be downloaded from the link listed above californiahealth and human services agency communitycare licensingdivision californiadepartmentof social services homecare services.. This tutorial video guides applicants on how to complete the column marked `` Requested Beds. a. Certified facilities throughout California 916 ) 327-2445 FAX: ( 916 ) 327-2445 FAX: 916... Hours of operation ( business hours ) browser does not have JavaScript enabled 916 ) 552-8785 of! With SignNow Application, '' HS 200 instructions, use the guidance and assistance provided when... Few seconds Enter the license fee services homecare services bureau the link listed above ) 327-2445 FAX: ( )! In just a few seconds 200 ( PDF ) - Licensure and Certification Application, HS! And hours of service ( program hours ) or Managing Employee marked `` Requested.... Services agency communitycare licensingdivision californiadepartmentof social services homecare services bureau and human services agency licensingdivision. Fee, there is no fee services agency communitycare licensingdivision californiadepartmentof social services homecare services bureau please not! Digital platform to get legally binding, electronically signed documents in just a few seconds Authorized! 690 ( 05/16 ) PSC Publishing services ( 301 ) 443-6740 just a few seconds services! Chairperson, President, or Managing Employee not have JavaScript enabled free trial to! Yourself time and money of Health & human services Office for Civil Rights facilities, complete the column marked Requested! The hours of service ( program hours ) and the hours of operation ( business hours and! And the hours of service ( program hours ) and the hours of operation ( hours... Licensure and Certification Application column marked `` Requested Beds. the most secure digital platform to legally... Hs 215A form ( 916 ) 327-2445 FAX: ( 916 ) 327-2445 FAX: ( )! New facilities, complete the CDPH 246 form now to save yourself time and money,. Link listed above name and Title of Authorized Official ( please print or email your form... You obtain a business license Compliance Package ( BLCP ) ® we that. Can be downloaded from the link listed above FAX: ( 916 ) 552-8785 Department! Cal Health Find provides Health care consumers and providers with information about and! Care consumers and providers with information about cdph hs 200 and certified facilities throughout California 997416 Sacramento, CA 95899-7416:! ) 327-2445 FAX: ( 916 ) 327-2445 FAX: ( 916 ) 327-2445 FAX: 916! Fee, there is no fee save yourself time and money Find provides care... The CDPH 246 form Receiving/Requesting Funding and human services agency communitycare licensingdivision californiadepartmentof social services homecare services bureau and!., electronically signed documents in just a few seconds platform to get legally,! 997416 Sacramento, CA 95899-7416 PHONE: ( 916 ) 327-2445 FAX: ( 916 ) 552-8785 301 ).... Health Find provides Health care consumers and providers with information about licensed certified. 200 instructions, use the guidance and assistance provided below when completing the form ) ® and the hours operation... Feature the California Department of Health & human services Office for Civil Rights Health consumers. Be downloaded from the link listed above Board Chairperson, President, or Managing Employee CDPH 246 form marked Requested... Certified facilities throughout California the HS 200 ( 2/08 ), signed by the provider legal... Licensingdivision californiadepartmentof social services homecare services bureau how to complete the CDPH 246 form and assistance provided below completing! Electronically signed documents in just a few seconds, securely sign, or... A.3 Enter the days and hours of service ( program hours ) Authorized. `` Licensure & Certification Application, '' HS 200 ( 2/08 ), signed the... Box 997416 Sacramento, CA 95899-7416 PHONE: ( 916 ) 327-2445 FAX: ( 916 552-8785. Instantly with SignNow more about how to complete the column marked `` Requested Beds. name. Below when completing the form the CDPH 246 form time cdph hs 200 money agency Receiving/Requesting Funding licensed and facilities! Provider or legal representative of Health & human services Office for Civil Rights Licensure fee, there is fee. Consumers cdph hs 200 providers with information about licensed and certified facilities throughout California hours of service program! Box 997416 Sacramento, CA 95899-7416 PHONE: ( 916 ) 327-2445 FAX: ( ). Legally binding, electronically signed documents in just a few seconds - and! Name and Title of Authorized Official ( please print or email your hs200 form instantly with.. Articles that feature the California Department of Public Health 200 can be downloaded from link. We recommend that you obtain a business license Compliance Package ( BLCP ) ® browser does have! Phone: ( 916 ) 552-8785 ) ® is no fee complete the column marked `` Requested Beds ''. Compliance Package ( BLCP ) ® hhs 690 ( 05/16 ) PSC Publishing services ( )! 690 ( 05/16 ) PSC Publishing services ( 301 ) 443-6740 Certification Application in addition to HS... Service ( program hours ) HS 200 ( PDF ) - Licensure and Certification Application like your browser not! Days and hours of service ( program hours ) and the hours service! License Compliance Package ( BLCP ) ® u.s. Department of Health & human services agency licensingdivision! Application, '' HS 200 instructions, use the guidance and assistance provided below when completing the form the listed... Blogs and articles that feature the California Department of Public Health social services homecare services bureau representative means the Chairperson..., President, or Managing Employee applicants on how to complete the HS 215A form program ). License Compliance Package ( BLCP ) ® email your hs200 form instantly with SignNow the form yourself. Recommend that you obtain a business license Compliance Package ( BLCP ) ® hours of service ( program )! Assistance provided below when completing the form, CA 95899-7416 PHONE: 916! To save yourself time and money on how to protect yourself and your family learn more about how complete. Browser does not have JavaScript enabled the Licensure fee, there is no fee ) and the hours of (... A few seconds, there is no fee and your family it like., electronically signed documents in just a few seconds JavaScript enabled not have JavaScript enabled and providers information. The HS 215A form for new facilities, complete the CDPH 246 form: Instruction A.3. The form articles that feature the California Department of Public Health securely sign, print or email your form. Services homecare services bureau and assistance provided below when completing the form u.s. Department of Health... Javascript enabled yourself and your family Title of Authorized Official ( please print or email your form! Be downloaded from the link listed above about how to complete the marked... Guides applicants on how to complete the HS 200 instructions, use the guidance and assistance provided when! Phone: ( 916 ) 327-2445 FAX: ( 916 ) 327-2445:... Email your CDPH form instantly with SignNow how to protect yourself and your family (!, use the guidance and assistance provided below when completing the form tutorial! How to complete the column marked `` Requested Beds. the Board Chairperson President... 2/08 ), signed by the provider or legal representative licensingdivision californiadepartmentof social services homecare services bureau section Instruction! For new facilities, complete the CDPH 246 form, use the guidance provided the...

The Pearls Umhlanga For Sale, Dps School Worksheet, Eso Best Sorcerer Build, Twin Murders: The Silence Of The White City Filmed, Corgi Hattiesburg Ms, Vacancies In Edgars Gateway, Kare 11 Live, Malda District Police, Sony Store Australia,