​​​​​​​Applications, Forms, and Fees​​

​The Department of Health Care Services (DHCS) has sole authority to license residential alcohol and/or drug treatment facilities. ​DHCS also offers voluntary facility certification to the programs that meet State Program Standards. This page contains the applications, forms and resources needed for licensure and certification.  

Applications

Please note: If you are interested in applying for both licensure and certification, you must complete both applicable forms (e.g., DHCS 6002 and DHCS 6040 for an initial application; DHCS 5999 and DHCS 6043 for extension/renewal). Ensure that both applications are included in the same submission. You do not need to submit duplicative accompanying documentation.

• Initial Treatment Provider Application (DHCS 6002)
• Initial Application for Certification (DHCS 6040)
• Initial Application for Existing Certified Programs To Obtain Initial Certification for New Program (DHCS 6041)​
• Application for Existing Licensee to Obtain Initial Licensure for New Facility​ (DHCS 6047)​
• Request for License/Certification Extension (DHCS 5999)​
• Application for Certification Renewal (DHCS 6043)​
• Application for Certification Amendment (DHCS 6042)​
• Supplemental Application Request for Additional Services (DHCS 5255)
  
• Sole Proprietor Application (DHCS 5111)
  

Supplemental Forms

• Incidental Medical Services Certification Form - Health Care Practitioner Client Assessment (DHCS 4026)
  
• Staff and Health Care Practitioner (HCP) Information (DHCS 5050)
  
• Health Screening Report (DHCS 5077)
  
• Program Director Information (DHCS 5082)​
• Administrative Organization - Corporation, Nonprofit Corporation Limited Liability Company, General Partnership or Limited Partnership (DHCS 5083)
• Administrative Organization - Public Agency or Sole Proprietor (DHCS 5084)
• Administrative Responsibility (DHCS 5085)
• Schedule of Recovery and Treatment Services (DHCS 5086)
• Client Health Questionnaire and Initial Screening Questions (DHCS 5103)
• Staff Health Questionnaire (DHCS 5105)
• Health Care Practitioner Incidental Medical Services Acknowledgement (DHCS 5256)​​

 Miscellaneous Forms​

• Centrally Stored Medication and Destruction Record (DHCS 5078)
• Incident, Injury or Death Report (DHCS 5079)
• Personal Rights - Alcohol Recovery and Drug Treatment Facilities (DHCS 5080)
• Derechos Personales - Facilidades de Recuperación y Tratamiento (DHCS 5080SP)
• Disclosure to DHCS (DHCS 5140)
• Detoxification Observation – Vital Signs Check Log (DHCS 6045)
  
• Detoxification Observation – Physical Check Log (DHCS 6046)​
  
• Consent to Electronic Service Agreement (DHCS 6048)​
  

​Fees

• ​BH Information Notice 25-017​ - SUD Recovery or Treatment Facilities’ Licensure and Certification Fee Increase Beginning Fiscal Year 2025-2026
• Hardship Fee Waiver (DHCS 6044)​
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