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āForms and Supportiāng Documentsāā
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āāAdditional Instructions
(āāāEach form listed also has instructions on the foāārm)ā
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āCover Letter
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Cover Letter
Letter on company letterhead with the following information:
- License number
- Facility name anād 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)ā
- 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 215A (PDF)ā
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āApplicant Individual Information
(REVISED 7/2023) (Health and Safety
Code (HSC)
section 1748(b); Standards of Quality Hospice Care (SQHC), 2005,
section 5.3).ā
This form must be completed for the following individuals and
include original signatures:
- Administrator, Administrator Designee, Director of Patient Care Services, Director of Patient Care Services Designee, and Medical Director or contracted Medical Director
- Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization
- Each individual having a beneficial interest of five percent or more in the applicant organization and/or parent organization
Tips:
- Page 2, section B, item 3 ā The date of birth is an identifier, as several people may have the same name. This will ensure each individual is associated with the correct facility or entity
- Page 2, section B, item 4 ā Provide your Driver's License Number or a State-Issued identification Card Number. Attached a copy of the Driver's License or State-Issued Identification Card for verification.
- Page 2, section B, item 5 ā The Social Security Number is an identifier, as several people may have the same name. this will ensure each individual is associated with the correct facility or entity
- Page 3, section B, item 7: Administrator must list the number of hours spent at each agency per week.
- Page 5, section E ā Submit ten years of employment history, indicating the start and end dates of employment, job title, employer name and address. The applicant may submit a resume in lieu of completing section D; however, the resume must contain all required information requested in section E
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HS 215A (PDF)
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Section H - Facility Information Sheet
Each individual must complete and submit the Facility Information Sheet for each facility and/or agency with which the individual has a current or past relationship within the last three years. This sheet must also include any facilities licensed by the California Department of Social Services. The following must be completed for each facility and/or agency:
- Facility name
- Facility address
- Type of facility
- Type of business entity (include EIN Number)
- Individual's nature of involvement
- Individual's dates of involvement
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āāSupporting Documents
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Resumeā
A resume is required for the Administrator, Administrator Designee, Director of Patient Care Services, Director of Patient Care Services Designee, and Medical Director or contracted Medical Directorā
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Supporting Documentsā
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Section D - Professional Licenses/Certificates
(Title 22 CCR Section 70211)
An active registered nursing license is required for the Director of Patient Care Services. Provide a printout of the current license from the Department of Consumer Affairs (https://search.dca.ca.gov/).
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