This form is used to provide organizational structure information that will be used to determine individual applicant’s or applicant facility’s ability to provide health services.

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. This 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., as required by law, even though no change in legal ownership is occurring.

This form is used to submit the actual effective date of a healthcare facility’s change of ownership.

This form is an agreement to conform to the provisions of section of 1866 of the Social Security Act and applicable provisions in 42 CFR and is required to be submitted in order to accept Medicare and/or Medicaid.

Use this form to apply for licensure and certification as a healthcare provider service or facility.

This form is used by Medi-Cal providers to disclose significant beneficial interests in other Medi-Cal providers by themselves or their family.