HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Contact Us

Phone: (916) 552-8632
Email: CAB@cdph.ca.gov

For application status requests, please include the following in your email:

Name of Facility or Agency
License or Facility/Agency # (if applicable)
Address
Facility or Provider Type
Date Documentation Sent
Contact Number

Primary Care Clinic - Intermittent Clinic

Notification Application Checklist for Change of Name

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 Name

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

Cover Letter

Letter on company letterhead with a brief description of the request and the following information:

Parent Clinic

Parent Clinic Name
Facility Address
Facility Number (if known)
License Number
Contact Information (name, title, phone number, and e-mail address)

Intermittent Clinic(s)

Facility Previous and New Name
Address
Hours of Operation
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: California Health Alert Network (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

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HEALTH CARE FACILITY LICENSING AND CERTIFICATION​​

Contact Us

Notification Application Checklist for Change of Name

Checklist and Instructions - Please submit your documents in this order

Required Documents for a Change of Name

HEALTH CARE FACILITY LICENSING AND CERTIFICATION