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Forms and Supporting Documentāsāā
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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
- Previous and proposed/new location
- 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/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, 1.5MB)
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Licensure & Certification Application
[Health and Safety Code (HSC) section 1212(a)]
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 ā Organizational Chart ā Owner Type
[HSC section 1212(a)]
Submit an organizational chart if the owner is a for profit corporation, nonprofit corporation, limited liability company (LLC), or general partnership. The organizational chart needs to display the following:
- Applicant's owners, including ownership percentages, Tax IDs/EINs and all directors, board members, corporate officers, LLC members/managers, and/or partners
Note: Submit the HS 215A form for each of these individualsā
- Parent company of applicant, if applicable, and all the licensed agencies/facilities it is operating - see B.6
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HS 215A (PDF)
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Applicant Individual Information
[Title 42 Code of Federal Regulation (CFR) section 485.56(a)]
[HSC sections 1212(a), 1225(c)(3)]
The form must be completed and signed for the following individual(s):
- Applicant Organization
- Owners, directors, board members, corporate officers, LLC members/managers, partners, and/or trustees of the applicant organization and/or Management Company
Tips
- Section B ā List applicant's legal name, nature of involvement to the facility, date of birth, driver's license or state-issued identification number and expiration date, social security number
- 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
- Section F ā If answering yes to any question in this section, complete and attach the facility information sheet (section H)
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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)
- Individual's nature of involvement
- Individual's dates of involvementā
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HS 309 Page 1 (PDF)
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Administrative Organization
[HSC section 1212(a)]ā
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
- Filing Statement from the Secretary of State
- Articles of Incorporation
- By-Laws
- List of Board of Directors (only if additional space is needed to input all board of directors)
Tip
- Page 1, item 3 ā The incorporation date is located in the top right corner of the Articles of Incorporation
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Supporting Documents
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Limited Liability Company (LLC)
- Filing Statement from the Secretary of State
- Articles of Organization
- Operating Agreement
- List of Managing Members (only if additional space is needed to input all managing members)
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HS 309 Page 2 (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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Supporting Documents
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Public Agency
Copy of signed Resolution
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Supporting Documents
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Partnership
Copy of signed Partnership Agreementāāā
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