Intermediate Care Facilities for the Developmentally Disabled: Medi-Cal Certification
Applicant Checklist (ICF/DD, ICF/DD-H, and ICF/DD-N)
The following forms and information are required for Medi-Cal certification. Note: All forms listed are in PDF format.
| Form # | āDescription | āCheck List |
| āHS 328 | āNotice ā Effective Date of Provider Agreement - If applying for both Medi-Cal & Medicare certification, only need one copy of this form.
| ā |
| āDHCS 6207 | āMedi-Cal Disclosure Agreement | ā |
| āDHCS 9098 | āMedi-Cal Provider Agreement - Do not leave any questions blank. Enter N/A or "same" if not applicable.
- The "mailing address" must be the same as reported on the HS 200 form.
- Signature page must be notarized.
- Submit the "Acknowledgement" page from the Notary Public, if applicable.
| ā |
| āāCMS 3070G | āIntermediate Care Facility for Persons with Mental Retardation Survey- This is a "survey" report. It will be completed during the licensing survey. The applicant only needs to complete the top portion of the form - the remainder will be completed during the survey.
| ā |