Form Dhcs 5112 - California Initial Certification Application - Health And Human Services Agency Page 7
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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
INITIAL CERTIFICATION APPLICATION
FOR ALCOHOL AND/OR OTHER DRUG PROGRAM CERTIFICATION
SECTION A
(Residential and nonresidential programs require separate applications).
F
D
U
O
(
)
OR
EPARTMENTAL
SE
NLY
PROGRAM ID:
DATE:
REVIEWED BY :
COUNTY:
D
T
F
(
)
IRECTIONS
O
ACILITY
1.
PROGRAM INFORMATION:
(Name of Program)
(Location to be certified)
(City/State)
(Zip)
(County)
(Telephone)
(Fax)
(E-mail Address)
(Mailing Address – if different from above)
(City /State)
(Zip)
DHCS 5112 (07/13)
Page 7 of 11
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