Ambulatory Surgery Center
Report of Change Application Checklist for Change of Property Owner
The following is a list of application forms and supporting documents required for a complete application packet. Failure to include each of the forms and documents will delay processing.
Checklist and Instructions - Pālease submit your documents in this order
Required Documents for a Change of Property Owner
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āForms and Supportingā Documentsāāā
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āāAdditional Instructions
(āāāEach form listed also has instructions on the form)ā
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āCover Letter
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Cover Letterā
Letter on company letterhead with the following information:
- Facility name and address
- Facility ID number (if known)
- Brief description of request
- Contact information (name, title, phone number, and e-mail address)
- Emergency Contact Information (name, email, alternate email, phone, fax, and phone number that will receive text messages). The Department will use this information to contact the provider in the event of an emergency using the California Health Alert Network (CAHAN). All information provided must allow CAHAN to contact the provider on a 24/7/365 basis for distribution of health alerts. For additional information:
CAHAN (https://www.calhospitalprepare.org/post/california-health-alert-network-cahanā)
- Contact Information for the Privacy Officer or Designee responsible for submitting and responding to medical breach incidents (name, title/position, mailing address, phone number, and email address)
- Signature
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āHS 200 (PDF, 1.5MB)
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Licensure & Certification Application
[Title 22 California Code of Regulation (CCR) section 51000.40 (a)]
Tip
- Attachment F-1 ā If the current or proposed facility, agency, or clinic is applying for Medi-Cal certification, complete Attachment F-1: Subcontractor Information and Significant Business Transactions
Note: Not applicable to Medicare providersā
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āSupporting Documents
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D.1 ā Control of Property
[22 CCR section 51000.60 (c)(9)(A)]
Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Aggeeāment between the owner of the property and the proposed entity
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