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 adult day health center, acute psychiatric hospitals, general acute care hospitals, special hospitals and skilled nursing 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, or bed classification. Name of facility Address (number, street) Type City State ZIP code Please enter the number of beds requested for each category: EXISTING BEDS _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Acute Respiratory Care Services Burn Center Cardiovascular Surgery Service Coronary Care Unit General Acute Care (Unspecified) General Nursing (Long-Term) Intensive Care (Newborn) Intensive Care Unit Pediatric Service Perinatal Unit Psychiatric Unit Rehabilitation Center Renal Transplant Center Respiratory Care Service Skilled Nursing Service (DP) Other (specify) ______________________ Other (specify) ______________________ REQUESTED BEDS _____ Acute Respiratory Care Services _____ Burn Center _____ Cardiovascular Surgery Service _____ Coronary Care Unit _____ General Acute Care (Unspecified) _____ General Nursing (Long-Term) _____ Intensive Care (Newborn) _____ Intensive Care Unit _____ Pediatric Service _____ Perinatal Unit _____ Psychiatric Unit _____ Rehabilitation Center _____ Renal Transplant Center _____ Respiratory Care Service _____ Skilled Nursing Service (DP) _____ Other (specify) ______________________ _____ Other (specify) ______________________ _____ APPROVED CAPACITY _____ APPROVED CAPACITY (For Departmental use only) ___________________________________________________________________________________________________ Please check services which the facility currently provides or is requesting: EXISTING SERVICES _____ _____ _____ _____ _____ _____ _____ _____ _____ Adult Day Program (only applies to an ADHC) Basic Emergency Physician on Duty Cardiovascular Surgery Chronic Dialysis Service Comprehensive Emergency Dental Service Nuclear Medicine Service Occupational Therapy Service Outpatient Service (i.e. Family Practice, Pediatrics, Primary Care, Rural Health Clinic, etc.) Specify: _____________________________ Specify: _____________________________ _____ Physical Therapy _____ Podiatric Service _____ Radiation Therapy _____ Social Service _____ Speech Pathology and/or Audiology Service _____ Other (specify): _______________________ _____ Other (specify): _______________________ CDPH 609 (12/11) REQUESTED SERVICES _____ _____ _____ _____ _____ _____ _____ _____ _____ Adult Day Program (only applies to an ADHC) Basic Emergency Physician on Duty Cardiovascular Surgery Chronic Dialysis Service Comprehensive Emergency Dental Service Nuclear Medicine Service Occupational Therapy Service Outpatient Service (i.e. Family Practice, Pediatrics, Primary Care, Rural Health Clinic, etc.) Specify: ____________________________ Specify: ____________________________ Physical Therapy Podiatric Service Radiation Therapy Social Service Speech Pathology and/or Audiology Service Other (specify): _______________________ Other (specify): _______________________ American LegalNet, Inc. www.FormsWorkFlow.com _____ _____ _____ _____ _____ _____ _____