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āForms and Supportingāā Documentsāā
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āāAdditional Instructions
(āāāEach form listed also has instructions on the form)ā
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āCover Letter
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Cover Letter
Letter on company letterhead with the following information:
- āLicense number (only applicable for CHOW)
- 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)
- Signatureā
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āHS 200 (PDF, 1.5MBā)
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Licensure & Certification Application
[Health and Safety Code (HSC) section 1212(a), 1225(c)(1)]
Tip
-
āAttachment 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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āSupporting Documents
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A.10 ā California Department of Health Care Access and Information (HCAI) [California Building Code section 1226 and HSC section 1226]
And/ Or Certificate of Occupancy
HCAI and Local Building Authority
One
of
the two documents are required:
-
Written certification: The local building authority or HCAI must provide written certification of Title 24 compliance (OSHPD 3 Standards) stating the building meets the current applicable codes and the following building requirements:
- California Building Code (CBC)
- California Fire Code (CFC)
- California Electrical Code (CEC)
- California Mechanical Code (CMC)
- California Plumbing Code (CPC)
- California Administrative Code (CAC)
-
CDPH 270: Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital, to certify the facility conforms to current applicable Title 24 (OSPHD 3 Standards). This form must be signed by the local
building
authority
or HCAI
Note: Title 24 compliance does not apply to CHOWS unless there has been construction and/or remodeling.
If
construction
occurred
and
if
the
construction
resulted
in
a
new building or addition:
- Submit a
Certificate
of
Occupancy
- This is not applicable if there were alterations or repairs to existing buildings performed or conversion of space
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āSupporting Documents
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āB.3 ā Internal Revenue Service Documentation
[HSC section 1212(a)]
Submit one of the following IRS tax documents showing entityās legal name and Tax Identification Number:
- Form 941- (Employerās Quarterly Federal Tax Return)
- Form 8109- C (FTD Address Change)
- Letter 147-C (EIN Confirmation Notification)
- Form SS-4 (Confirmation Notification)
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Supporting Documents
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B.3
ā
Organizational Chart ā Owner Type
[HSC section 1212(a)] [42 CFR section 494.180]
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:ā
- Applicantās 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 individuals
- Parent company of applicant, if applicable, and all of the licensed agencies/facilities it is operating - see B.6
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āSupporting Documents
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āB.3
ā
Non-Profit Status ā Owner Type
[HSC section 1212 (a)]
Submit a copy of the IRS Tax Exempt Determination Letter showing the non-profit 501(c) (3) status, if applicable
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āSupporting Documents
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āB.4.b
ā
License Revocation
(if applicable)
[HSC section 1212 (a)]
Submit additional information, including all ownership and facility information, date and any final action
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āSupporting Documents
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āB.6
ā
Organizational Chart
[HSC section 1225 (a)] [42 CFR 494.180]
If licensee is a subsidiary of another organization, include an organizational chart
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Supporting Documents
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āD.1
ā
Control of Property
(only
required
for
new property)
[HSC 1212(a)]ā
Submit a copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed Licensee
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āSupporting Documents
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Floor Plan
[HSC section 1212(a)(9)]
Submit a floor plan that coincides with your office spaceā
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āHS 215A (PDF)ā
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āApplicant Individual Information
[HSC section 1212 (a), 1212(a)(6)] [Title 42
California Code of
Federal
Regulation (CFR) sections 420.206(a)(3), 455.104, 494.140 subdivisions (a) and (b)(1), 494.180 subdivisions (a), (b) and (j)]
This form must be completed for the following individuals:
- Administrator of
the
facility,
Medical
Director
and
the Director
of
Nursing
-
Owners, directors, board members, corporate officers, LLC members/managers, and partners of the parent, grandparent, great
grandparent,
and etc. organization, if
applicable
- Each individual having
a beneficial interest
of
exceeding five percent or more in the applicant organization and/or parent, grandparent, great grandparent, and etc.
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 Sheetā
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Supporting Documentsā
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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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āSupporting Documents
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āResume
[42 CFR 494.140 (a)(1), 494.140 (b)(1)(iii)]
A resume is only required for the Administrator(s), Director of Nursing, and Medical Director
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āSupporting Documents
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āProfessional Licenses/ Certificates
[HSC sections 1212(a)] [42 CFR 494.140 subdivisions (a) and (b)]
- An active registered medical license is required for the Medical Director and Director of Nursing
- Provide a printout of the current license from the
Department of Consumer Affairs (https://seaārch.dca.ca.gov/)
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HS 309 1st Pageā (PDF)
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Administrative Organization
[HSC section 1212 (a)] [42 CFR 494.180]
Along with the HS 309, the following supporting documents according to organizational type must be submitted:
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Supporting Documentsā
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Corporation
[HSC section 1212(a)]
- Filing Statement from CA Secretary of State (only if Articles of Incorporation are not endorsed by the CA Secretary of State)
- Articles of Incorporation (Endorsed by CA Secretary of State)
- By-Laws (Stating the size of boards)
- 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 located in the top
right
corner
of
the
applicant
Articles
of
Incorporation
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Supporting Documentsā
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Limited Liability Company (LLC)
[HSC section 1212(a)]
- 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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āHS 309 2nd Pageā (PDF)
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Organizational Structure
Only complete fields that are applicable to applicantās entity type
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āSupporting Documents
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Partnership
[HSC section 1212(a)]
Copy of signed Partnership Agreement
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āSupporting Documents
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āOut of State Corporations
[HSC 1212 (a)]
Copy of the Certificate of Qualification from the CA Secretary of State allowing the applicant to do business in California
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HS 602ā (PDF)
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Transfer Agreement
[42 CFR 494.180(g)(3)]
Copy of current (within one year of submission of application) written transfer agreement with hospital appropriate to meet medical emergencies
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āFire Safety Inspection Request
[42 CFR 494.60 (d)(3)]
The STD 850 form is required. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form.
- This form is not required for a CHOW unless there has been construction and/or remodeling.
- 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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