Forms and Supporting Documents
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Additional Instructions
(Each form listed also has instructions on the form)
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Cover Letter
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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
- 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:
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
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HS 200 (PDF, 1.6MB)
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Licensure & Certification Application
[Title 22 California Code of Regulations (CCR) section 75021]
Tip
- 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
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Supporting Documents
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B.3 - Organizational Chart ā Owner Type
[Health and Safety Code (HSC) 1212(a)]
Submit an organizational chart, for the nonprofit corporation. The organizational chart needs to display the following:
- Applicantās directors, board members, and corporate officers (corporate officers as defined in the By-Laws)
Note: Submit the HS 215A form for each of these individuals
- Parent company of applicant, if applicable, and all of the licensed agencies/facilities they are operating- see B.6
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Supporting Documents
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B.3ā Non-Profit Status ā Owner Type
[HSC section 1204(a)(1)(A)(B)] [22 CCR section 75022(a)(3)]
Submit a copy of the IRS Tax Exempt Determination Letter showing the non-profit 501(c)(3) status
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Supporting Documents
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B.4.bā License Revocation (if applicable)
Submit additional information, including all ownership and facility information, date and any final action
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Supporting Documents
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āB.6
ā
Organizational Chart
[HSC section 1212(a)]
If licensee is a
subsidiary of another organization, an organizational chart must be submitted
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HS 215A (PDF)
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Applicant Individual Information
[HSC section 1212(a)] [22 CCR sections 75022]
This form must be completed for the following individuals:
- Administrator of the facility
- Applicant Organization
- Directors, board members, corporate officers (CEO, President, COO, CFO), LLC members/managers and partners of the applicant organization
- Parent Company (if applicable)
- Directors, board members, corporate officers, LLC members/managers, and partners of the PARENT organization
Tips
- Page 2, section B ā 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 ā 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 ā If answering yes to any question in this section, complete Section H: Facility Information Sheet
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Supporting Documents
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Facility Information Sheet
Each individual must complete and submit the Facility Information Sheet for each facility and/or agency with which the individual has a current or past relationship within the last three years. This sheet must also include any facilities licensed by the California Department of Social Services. The following must be completed for each facility and/or agency:
- Facility name
- Facility address
- Type of facility
- Type of business entity (include EIN Number)
- Individualās nature of involvement
- Individualās dates of involvement
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Supporting Documents
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Resume
[HSC section 1212(a)] [22 CCR section 75022(a)(4), 75045(d), 75046(b)]
A resume is required for the Administrator
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HS 309 1st Page (PDF)
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Administrative Organization
[22 CCR section 75022(a)(2)]
Along with the HS 309, the following supporting documents according to organizational type must be submitted:
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Supporting Documents
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Corporation
- Articles of Incorporation endorsed by CA Secretary of State
- Filing Statement from CA Secretary of State (only if Articles of Organization are not endorsed by the CA Secretary of State)
- By-Laws stating size of the Board
- List of Board of Directors (only if additional space is needed to input all board of directors)
Tip
- Page 1, item 3 ā The applicant can find the incorporation date located in the top right corner of the Articles of Incorporation
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HS 309 2nd Page (PDF)
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Organizational Structure
Only complete fields that are applicable to applicantās entity type
Tip
- Page 2, item 1 ā Health care districts will fill in the circle for other
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Fire Safety Inspection Request
[HSC section 1765.155(a)]
- The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form
- If the STD 850 form is not required for a particular mobile clinic, a written statement from the local fire agency must be submitted
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