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
• Include previous and proposed/new name
• Previous and proposed/new name
• 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/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 
  

[HSC section 1212(a)]

Submit a Board Resolution approving name change

• 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 — The incorporation date is located in the top right corner of the Articles of Incorporation
  

Only complete fields that are applicable to applicant’s entity type

Tip

• Page 2, item 1 — Health care districts will fill in the circle for other

Copy of signed Partnership Agreement