Application Materials

Dual Program ADHC/ADP Application Instructions (Rev 07/2023)
Second or dual program application requirements
- Instructions
Center Change Applications
CDA Pre-Approval Required
Beginning February 15, 2023, CBAS providers shall submit all change application packets (Administrator & Program Director, License Capacity, Location, Ownership, and Shareholder) to CDA first via the PEACH provider portal. CDA, in collaboration with the California Department of Public Health (CDPH), has implemented a change to this process which will help streamline and reduce processing timeframes for change application packet reviews. Upon submission of a change application packet, CDA will conduct an initial review and determine if the provider meets the minimum CBAS program standards. After the initial CDA review is complete, CDA will notify the CBAS provider of its determination and forward copies of the application packet to the CDPH – Centralized Applications Branch (CAB) along with a notice of CDA's recommendation. CDPH will notify the provider if the application packet is approved or deemed incomplete based on compliance with state licensure requirements. Please review All Center Letter (ACL) 23-01.
Center change application requirements.
Certification Renewal Application
Certification renewal applications requirement. Submit every 24 months to maintain continued certification.
Resource Guide

Application Forms

ADHC/CBAS License Capacity Increase (02/2024) – Projected Growth Plan

CDA ADH 0006 (02/2024) – Staffing Services Arrangement

CDA ADH 0006i (02/2024) – Staffing Services Arrangement Instructions

CDA ADH 0007 (02/2024) – Proposal to Share Space

CDPH 325 (02/2023) – Criminal Record Clearance

CDA ADH 1038 (02/2024) – Acknowledgement of Regulatory Responsibilities and Practice Acts

CDA CBAS 406 (11/2023) – Disclaimer of Conflict of Interest

CDA CBAS 4007 (02/2024) – Contractual Agreement Listing

CDA 7006 (02/2024) – Personal Identifying Information

CDA 7006i (03/2024) – Personal Identifying Information Instructions

CDA 7007 (02/2024) – ADHC/CBAS Pre-Screening Training Modules Completion Form

DHCS 1051 (06/2019) – Civil Rights Compliance Review

DHCS 9098 (07/2017) – Medi-Cal Provider Agreement

HS 200 (07/2023) – Licensure and Certification Application

HS 215A (07/2023) – Applicant Individual Information

HS 309 (10/2011) – Administrative Organization

CDA IMS 33 (11/2023) – Balance Sheet

CDA IMS 35 (02/2024) – Cash Flow Forecast

CDA IMS 36 (09/2024) – Provider Participation Agreement

CDA IMS 37 (02/2024) – Operating Budget