​Back to Licensing and Certification

 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

• Initial Treatment Provider Application (DHCS 6002)
• Request for License/Certification Extension (DHCS 5999)
• Supplemental Application Request for Additional Services (DHCS 5255)
• Sole Proprietor Application (DHCS 5111)

Supplemental Forms

• Administrator/Director Information (DHCS 5082)
• Administrative Organization - Corporations (DHCS 5083)
• Administrative Organization - Public Agencies, Partnerships, Sole Proprietor, and Other Associations (DHCS 5084)
• Administrative Responsibility (DHCS 5085)
• Facility Staffing Data (DHCS 5050)
• Weekly Activities Schedule (DHCS 5086)
• Health Screening Report (DHCS 5077)
• Client Health Questionnaire and Initial Screening Questions (DHCS 5103)
• Staff Health Questionnaire (DHCS 5105)
• Incidental Medical Services Certification Form - Health Care Practitioner Client Assessment (DHCS 4026)
• Health Care Practitioner Incidental Medical Services Acknowledgement (DHCS 5256)

 Miscellaneous Forms

• Centrally Stored Medication and Destruction Record (DHCS 5078)
• Unusual Incident/Injury/Death Report Form (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)

Fire Clearance And Zoning (Outpatient)

• Outpatient Fire Clearance (DHCS 5104)
• Zoning Approval Form (DHCS 5115)

Fees

• MHSUD Information Notice 14-022 – Increased Assessment of Fees