Cover Letter

Letter on company letterhead with the following information:

• License number
• Facility name and ID number (if known)
• Brief description of request
• 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​

Section D - Property Information 

Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee

• If the licensee owns the property, submit a signed copy of the Grant Deed, or Bill of Sale  
• If the licensee rent, lease, or sublease, submit the signed copy of the agreement (i.e., rental agreement and/or master lease between the property owner/manager and the perspective licensee)