Form Dhcs 5112 - California Initial Certification Application - Health And Human Services Agency Page 4
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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
Recovery and/or Treatment Facilities, issued on October 11, 2007, and posted on DHCS’s website at
Effective August 24, 2007, the following Residential Licensure Fees will be assessed by DHCS.
Residential and/or Outpatient Certification Fees
Initial Residential and/or Outpatient Certification Application Fee
$ 2,664
Biennial Outpatient Certification Initial/Extension Fee
$ 3,452
Combined Residential Licensure and Certification Fee
Initial Combined Residential Licensure and Certification Application Fee
$ 3,698
*Biennial Combined Residential Licensure and Initial/Extension Fee **
$ 147 (per bed)
*Residential facilities that are also certified will be assessed based on a per bed extension fee.
DHCS 5112 (07/13)
Page 4 of 11
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