Referral Agency
Report of Change Application Checklist for Change of Mailing Address
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 - Pālease submit your documents in this order
Required Documents for a Change of Mailing Address
|
Forms and Supporting Documentsāā
|
āāAdditioānal Instructions
(āāāEach form listed also has instructions on the form)ā
|
|
āCover Letteāār
|
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
|
āHS 200 (PDF, 1.5MB)
|
Licensure & Certification Applicationā
[Health and Safety Code (HSC) section 1409.3(c)] and [Title 22 California Code of Regulations (CCR) section 74119(c)]
Tip
- āPage 6, section B, item 6 ā An organization will have its own Federal tax ID number
|
ā