Get Hs 215

Filling out the Hs 215 form is a crucial step in the application process for health facilities and community care providers in California. This guide outlines each section of the form to ensure users can complete it accurately and confidently.

Follow the steps to successfully complete the Hs 215 form online.

1. Press the ‘Get Form’ button to access the Hs 215 form and open it in your preferred editing tool.
2. Enter the proposed name of your facility, agency, or clinic as required. This information should match what is listed in your application.
3. In the applicant individual information section, provide your full name, date of birth, and business address, including city, state, and zip code.
4. Specify your title in relation to the facility. If you are an administrator, indicate the hours you will spend at the clinic each week.
5. Respond to the criminal record questions. If applicable, provide details of any convictions or health service fraud judgments.
6. List any professional licenses or certificates you hold, including the type, period held, and issuing agency.
7. Provide a summary of your employment history for the past 10 years, including names, addresses, job titles, and dates of employment.
8. Answer questions related to facility, agency, and clinic involvement. If any questions receive a 'yes' response, complete the attached Facility Information Sheet.
9. In the adverse actions section, indicate if you've been affiliated with a facility that has faced adverse actions and provide explanations if necessary.
10. Sign and date the form to declare the accuracy of the information provided. Ensure that the signature is original and dated within the last three months.
11. Once you have completed all sections, review the form for accuracy. After confirming that all information is correct, save your changes, and consider downloading, printing, or sharing the completed form.

Complete your Hs 215 form online today for a seamless application process.