Primary Care Clinic - Affiliate Mobile
Report of Change Application Checklist for Change of Mailing Address
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 - Please submit your documents in this order
Required Documents for a Change of Mailing Address
Forms and Supporting Documents
| Additional Instructions
(Each form listed also has instructions on the form)
|
Cover Letter
| Cover Letter Letter on company letterhead with the following information: - License number
- Facility name and address
- Facility ID number (if known)
- Brief description of request
- Indicate if the change of mailing address is for the Licensee or for the facility
- Days and hours of operation
- Locations serviced by mobile unit
- Contact information (name, title, phone number, and
email 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: CAHANā (https://www.calhospitalprepare.org/post/california-health-alert-network-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
|
HS 200 (PDF, 1.5MB)
| Licensure & Certification Application [Title 22 California Code of Regulation (CCR) section 75021] [Health and Safety Code (HSC) sections 1212, 1218.1, 1765.130]
Tipā
- 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
|
Medi-Cal Certification Documents
Forms and Supporting Documents
| Additional Instructions
(Each form listed also has instructions on the form)
|
DHCS 9098 (PDF)ā
| Medi-Cal Provider Agreement
- Do not leave any questions blank. Enter āsameā or āN/Aā if not applicable
- The mailing address must be the same as reported on the HS 200 form, section C, Page 3, item 4
- Notarized signature page is required
- Submit the āAcknowledgementā page from the notary public
|
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