Form Hcs 200a - Intent To Apply For A Home Care Organization License
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1
2CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
HOME CARE SERVICES BUREAU
INTENT TO APPLY FOR A HOME CARE
For Department Use Only
HOME CARE ORGANIZATION NUMBER
ORGANIZATION LICENSE
COUNTY
California Health and Safety Code Section 1796.61(b) allows Home Care Organization applicants who submit
applications prior to January 1, 2016, to continue providing services while going through the application
APPLICATION FILED?
DATE FILED
process. Home Care Organization applicants shall use this form to meet the requirements of this section.
YES
NO
This form must be submitted to the Home Care Services Bureau on or before December 31, 2015. In addition,
a completed application package with the $5,165 application fee must be submitted to the Home Care Services
FEES INCLUDED?
AMOUNT
Bureau by March 1, 2016. Please note that the $5,165 application fee is not required with this intent form. For
YES
NO
instructions on how to complete this form refer to page two.
APPLICANT NAME
AREA CODE/TELEPHONE
(
)
APPLICANT MAILING ADDRESS
CITY
STATE
ZIP CODE
I
I
I
I
APPLICATION
D. PROFIT CORPORATION
A. INDIVIDUAL
B. PARTNERSHIP
C. NON PROFIT CORPORATION
INTENT FILED BY:
I
I
I
G. LIMITED LIABILITY CORPORATION
E. COUNTY
F. OTHER PUBLIC AGENCY
EMAIL ADDRESS
AREA CODE/TELEPHONE
HOME CARE ORGANIZATION NAME
(
)
CITY
HOME CARE ORGANIZATION STREET ADDRESS
COUNTY
ZIP CODE
ALT. PUBLIC TELEPHONE
(
)
HOME CARE ORGANIZATION MAILING ADDRESS
CITY
STATE
ZIP CODE
TITLE
DESIGNEE/REPRESENTATIVE OF HOME CARE ORGANIZATION
TOTAL NUMBER OF HOME CARE AIDES
I/WE DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS ON THIS
INTENT APPLICATION ARE CORRECT TO THE BEST OF MY/OUR KNOWLEDGE.
SIGNATURE OF HOME CARE ORGANIZATION APPLICANT
DATE
TITLE
NAME OF HOME CARE ORGANIZATION APPLICANT
PAGE 1 OF 2
HCS 200A (10/15)
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