TYPE HS 215A 2/08 PERIOD HELD ISSUING AGENCY D. Employment/Business Summary for last 10 years. Please list any additional experience that qualifies you to operate this type of facility. Refer to the INSTRUCTION SHEET to see who needs to complete this form. This HS 215A 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...
hs 215a

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Who needs a form HS 215 A?

People wanting to open a hospice or a home health agency in California, need a license and must file this application together with other mandatory forms in order to obtain licensure and certification from the California Department of Public health.

What is form HS 215 A for?

Form HS215A stands for “Applicant Individual Information”. Its purpose is to provide the identifying information about a business entity and its owners to the Health and Human Service Agency. If HHSA representatives approve this form, the entity is granted a right to provide health care services. It’s worth mentioning that the whole package of forms must be approved for licensure, not just the HS215A.

Is it accompanied by other forms?

Yes, it is. You need to look up the right forms for the type of agency you are going to open. Find the checklist of requested forms here.

When is form HS 215 A due?

You must wait for the agency to process your application package before you start offering your services.

How do I fill out a form HS 215 A?

On the first page you should provide general information about the owner who applies for a health license. Name the criminal records, if any and list the licenses and certificate in case you apply for a primary clinic. Write your employment summary over the last 10 years, and fill out the Facility Information Sheet.

Where do I send it?

Completed applications and their companion forms must be sent to the following address:

California Department of Public Health

Licensing and Certification Program

Centralized Applications Unit

P.O. Box 997377, MS 3402

Sacramento, CA 95899-7377

Video instructions and help with filling out and completing hs 215a