State of California—Health and Human Services Agency California Department of Public Health Date BED OR SERVICE REQUEST This form is intended to identify the types of beds or services requested for health facilities. For new facilities, complete the column marked “Requested Beds.” For existing facilities, complete both columns. The form is to accompany the application form (HS 200) for any new facility, change in capacity, service, facility type, or bed classification. Name of facility Type Address (number, street) City State ZIP code Please insert number: EXISTING BEDS REQUESTED BEDS Acute Respiratory *Burn Coronary Care General Nursing (Long-term) Intensive Care *Intensive Care (Newborn) Intermediate Care Medical—Surgical Mental (Long-term) Pediatrics Perinatal *Psychiatric Rehabilitation Other (specify): Acute Respiratory *Burn Coronary Care General Nursing (Long-term) Intensive Care *Intensive Care (Newborn) Intermediate Care Medical—Surgical Mental (Long-term) Pediatrics Perinatal *Psychiatric Rehabilitation Other (specify): APPROVED CAPACITY APPROVED CAPACITY Please check services: EXISTING SERVICES *Basic Emergency *Cardiovascular Surgery *Chronic Dialysis Unit *Comprehensive Emergency Dental Nuclear Medicine Occupational Therapy Outpatient Service Physical Therapy Podiatric Service *Radiation Therapy *Renal Transplant Center *Respiratory Care Social Service Speech Pathology/Audio Standby Emergency Clinic Only: Abortion Service Birthing Service Psychology Other (specify): REQUESTED SERVICES *Basic Emergency *Cardiovascular Surgery *Chronic Dialysis Unit *Comprehensive Emergency Dental Nuclear Medicine Occupational Therapy Outpatient Service Physical Therapy Podiatric Service *Radiation Therapy *Renal Transplant Center *Respiratory Care Social Service Speech Pathology/Audio Standby Emergency Clinic Only: Abortion Service Birthing Service Optometric Psychology Other (specify): *Special Permit Services HS 609 (2/08) American LegalNet, Inc. www.FormsWorkflow.com