Cover Letter

Letter on company letterhead with the following information:

• License number
• Facility name and 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/cahan)
  
• 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​

• ​The service area of a parent HHA may not extend beyond four hours surface travel time from the agency unless the agency serves a rural, scarcely populated area
• Submit a list of the geographical areas (including cities, counties, and zip codes) to be served
• Submit a web-based map

• This application is from the Federal Department of Health and Human Services
• The completed application should be mailed directly to the appropriate fiscal intermediary