​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