Cover Letter

Letter on company letterhead with the following information:

• License physical address
• 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: 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
  

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

Organizational Structure

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
  

Partnership

Copy of signed Partnership Agreement

Licensure & Certification Application

Tip

• Attachment F-1 — 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 
  

Applicant Individual Information

[Title 42 Code of Federal Regulations (42 CFR) section 455 Subpart B]

• Sections A, B, C, and G 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
  

• Each individual having a direct or indirect beneficial interest of five percent or more in the applicant organization and/or parent company
  

Tip

• Section B – 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