Cover Letter

Letter on company letterhead with the following information:

• Proposed Parent Clinic

• Facility name and address
• Licensee physical address
• License number
• Facility ID number (if known)
• Brief description of request
• Statement that the PCC is in compliance with the following:
• There is a single governing body for all the facilities maintained and operated by the licensee
• There is a single administration for all the facilities maintained and operated by the licensee
• Corporation name and administrative office address
• Contact information for Chief Executive Officer or Executive Director (name, title, and phone number)
• 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)

• ​​​Consolidated Clinic

• ​​​Facility name and address
• Facility ID number (if known)
  
• Hours of operation
  
• Services provided
  
• National Provider Identifier (NPI)
  
• 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​)
• Signature​

Organizational Chart – Owner Type

[HSC section 1212(d)]

Submit an organizational chart for the nonprofit corporation. The organizational chart needs to display the following:

• Single governing body, including the board of directors, for all the facilities operated and maintained by the licensee
• Single administration for all the facilities operated and maintained by the licensee

Applicant Individual Information

[HSC section 1212(a)] [22 CCR sections 75022, 75025]

This form must be completed and signed for the following individuals:

• Administrator of the facility
• ​New directors, board members, and corporate officers of the applicant organization

​​Note: Corporate officers as defined in the By-Laws

• Page 2, section B — The date of birth is an identifier, as several people may have the same name. This will ensure that each individual is associated with the correct facility or entity
• Page 5, section E — 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 E; however, the resume must contain all required information requested in section E
• Page 7, section F — If answering yes to any question in this section, complete Section H: Facility Information Sheet
  

​​Resume

[22 CCR sections 75022(a)(4), 75045(d), 75046(b)]

A resume is required for the Administrator

Only complete Section V

Notice – Effective Date of Provider Agreement

Submit one copy of the HS 328 form with original signature

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