Cover Letter

Letter on company letterhead with the following information:

• Proposed Parent Clinic
• Facility name and ID number (if known)
• Licensee physical address
• License number
• 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
• There is a single medical director for all the facilities maintained and operated by the licensee, with a single set of bylaws, rules and regulations
• Corporation name and administrative office address
• Contact information for Chief Executive Officer or Executive Director, and Medical Director (name, title, and phone number)
• ​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 

Applicant Individual Information

[HSC section 1212(a)] [Title 22 California Code of Regulations (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 (Chief Executive Officer (CEO), President, Chief Operations Officer (COO), Chief Financial Officer (CFO)), of the applicant organization 

• 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

[HSC 1212(a)] [22 CCR sections 75022(a)(4), 75045(d), 75046(b)]

A resume is required for the Administrator

[HSC section 1765.120(a)]

Submit copy of DMV registration documents, indicating:

• Vehicle Identification Number (VIN)
• Type of vehicle
• ​Manufacturer

[HSC section 1765.155(a)]

• Submit a copy of the Local Planning/Zoning approval
• If the Local Planning/Zoning approval is not required for a particular mobile clinic, CAB needs a written statement from the Local Planning/Zoning agency
  

Only complete Section V

Applicant for Medi-Cal Certification as a Primary Care Clinic Provider

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

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