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State of California - Health and Human Services (Department of Health Care Services)

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State of California - Health and Human Services Agency
Department of Health Care Services
Licensing and Certification Division
Licensing Branch 1, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
(916) 322-2911
Request for License and/or Certification Ext ension
Please review the following information and note any changes. This document must be COMPLETELY
FILLED OUT, SIGNED BY AN AUTHORIZED REPRESENTATIVE(S) and received by Department of
Health Care Services (DHCS). Please submit the Request for License and/or Certification Extension
DHCS Form 5999 (12/18) with all supporting documentation, renewal fees and any civil penalties to the
department.
In accordance with the Alcohol and/or other Drug Program Certification Standards, Section 3000(b), the
program shall submit the Request for License and/or Certification Extension DHCS Form 5999 (12/18)
with all supporting documentation and renewal fees to the department 120 days prior to the expiration
date reflected on the certificate. Failure to provide all necessary documentation shall result in the
termination of the certification in accordance with Section 3000(d).
Have there been any changes since your current license/certification was issued? ☐ Yes ☐ No
If you answered yes to the above question please contact your analyst at (916) 322-2911. Please have
your provider number (license/certification number) ready. Failure to do so may result in a delay or
termination of your request for extension.
This form shall be returned with fees payable to: DHCS (i.e. license fees, civil penalties, etc.), via mail.
Please include your provider number (license or certification number) on all correspondence. You
must complete all fields on this application. Incomplete applications will be returned unprocessed
and may delay the extension of your licensure/certification.
Provider Number (License/Certification Number):
Legal Entity Name:
Mailing Address:
City:
State:
Zip Code:
Phone:
Facility Name:
Facility Address:
City:
State: CA
Zip Code:
Phone:
Website:
Fax:
Email:
Contact Person:
Phone:
Email:
Director’s Name:
Phone:
Email:
Type of Organization:
☐ Profit Corporation ☐ Nonprofit Corporation
☐
Sole Proprietor
☐ Partnership
☐ Government Entity
TYPE OF SERVICE(S) PROVIDED:
TARGET POPULATION:
☐
Detoxification
☐
Educational Sessions
☐
Group Sessions
☐
Individual Sessions
☐
Recovery/Treatment Sessions
CERTIFICATION
☐
Day Treatment
☐
Detoxification
☐
Outpatient
☐
Residential
☐
Co-Ed
☐ Men Only
☐
Women Only
☐
Men Only or Women Only
☐
Youth/Adolescents
☐
Parents/Children # of Children:
Continue to Page 2
DHCS 5999 (Revised 03/2020)
Page 1 of 2
State of California - Health and Human Services Agency
Request for License and/or Certification Extension
ADDITIONAL ITEMS:
RESIDENTIAL FACILITIES ONLY:
(Required of all applicants)
(Required)
1)
DHCS 5050 - Facility Staffing Data
3)
A Valid Fire Clearance
2)
DHCS 5086 - Weekly Activities Schedule
4)
A Line Item Budget
Treatment/Recovery Capacity:
Total Building Capacity:
Date of Current Fire Clearance:
California Health and Safety Code § 11834.01(a) and the Alcohol and/or Other Drug Program
Certification Standards § 3000 require all licensed and/or certified providers of alcohol and other
drug services, respectively, to request extension of the license and/or certification every two
years. Chapter 5, Title 9 California Code of Regulations § 10529(a) (2) and Alcohol and/or Other
Drug Program Certification Standards § 3010 specifies the items to be provided in order to have
the license and/or certification extended. Civil Code, § 1798.17 and the Privacy Act of 1974, 5
USC 552a, provide protection to individuals by ensuring that personal information collected by
state agencies is limited to that which is legally authorized and necessary and is maintained in a
manner which precludes unwarranted intrusions upon individual privacy.
CERTIFICATIONS AND ASSURANCES
I certify under penalty of perjury that I have read, understand, and will comply with the
regulations and/or standards that govern the operation of the program for which I am applying.
I further certify, under penalty of perjury, that the information contained in this application is
accurate, true and complete in all material aspects.
I certify under penalty of perjury that all program policies and procedures required by the
regulations and/or standards that govern the operation of this program have been developed,
comply with the appropriate regulations and standards, and are available for review by the
DHCS upon request.
I certify under penalty of perjury that the applicant does not discriminate in employment
practices or provision of services on the basis of race, national origin, ethnic group,
identification, religion, age, sex, sexual orientation, color or disability pursuant to the Title VI,
Civil Rights Act of 1964, (42 U.S.C. Chapter 21), The Americans with Disabilities Act of 1990
(42 U.S.C. § 12132), California Government Code § 11135, The Rehabilitation Act of 1973 (29
U.S.C. § 794), and Title 9, California Code of Regulations, Commencing with § 10800.
a.
If the applicant is a sole proprietor, the application shall be signed by the proprietor.
b.
If the applicant is a partnership, the application shall be signed by each partner.
c.
If the applicant is a firm, association, corporation, county, city, public agency or
other governmental entity, the application shall be signed by the chief executive
officer or an individual authorized to represent the provider.
Please print, sign in blue ink, and send this completed form and the additional items required
(from page one) to DHCS. Attach additional signature pages if necessary.
Signature of Authorized Individual
Print Name
Title
Date
Signature of Authorized Individual
Print Name
Title
Date
Signature of Authorized Individual
Print Name
Title
Date
DHCS 5999 (Revised 03/2020)
Page 2 of 2
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State of California - Health and Human Services (Department of Health Care Services)

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Completed 9 December 2021

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