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State of California—Health and Human Services Agency
California Department of Public Health

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 #​Description​Check List
HS 328

​Notice – Effective Date of Provider Agreement

  • If applying for both Medi-Cal & Medicare certification, only need one copy of this form.
DHCS 6207

​Medi-Cal Disclosure Agreement

  • Only complete section V.
DHCS 9098

​Medi-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.
​​CMS 3070G​Intermediate 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.

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