Form Dhcs 5112 - California Initial Certification Application - Health And Human Services Agency
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11STATE OF CALIFORNIA--HEALTH AND HUMAN SERVICES AGENCY
Department of Health Care Services
Licensing and Certification Branch, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
ALCOHOL AND/OR OTHER DRUG PROGRAM
INITIAL CERTIFICATION APPLICATION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
SUBSTANCE USE DISORDER COMPLIANCE DIVISION
LICENSING AND CERTIFICATION BRANCH, MS 2600
PO Box 997413
SACRAMENTO, CA 95899-7413
Phone (916) 322-2911 FAX (916) 322-2658 TTY (916) 445-1942
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DHCS 5112 (07/13)
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