​​​​​​​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)
• 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)
• Weekly Activities Schedule (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)​
  

Fire Clearance And Zoning (Outpatient)

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

Fees

• BH Information Notice 24-022​​ - SUD Recovery or Treatment Facilities’ Licensure and Certification Fee Increase Beginning Fiscal Year ​​2024-2025​​
  
• 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)​