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
• Days and hours of operation
• Current and proposed services
• 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: CAHAN​ (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 
  

Cover Letter (see cover letter requirements)

Complete, sign, and date

Tips

• A Change of Ownership means the non-profit corporation owning and operating the primary care clinic does not share the same federal tax identification number as the previous number
• The HS 269 form requires a National Provider Identifier number in lieu of the Medi-Cal provider number
• Page 1, question 4 - the specific type of service, advice, and treatment matches any other document included with your application
• Page 1, question 5 - list Medi-Cal as a source of funds
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