Cover Letter

Letter on company letterhead with the following information:

• License number
• Facility name and address
• Indicate if the change of the name is for the Licensee and/or the Facility
• Facility ID number (if known)
• Brief description of request
  
• Previous and ​proposed/new name
  
• 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/c​ahan)
• 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​
  

Board Resolution

[HSC section 1265(i)]

Submit a copy of board resolution signed by officers and directors authorizing the facilit​y name change and with the effective date.

• Do not leave any questions blank. Enter “same” or “N/A” if not applicable
• The mailing address must be the same as reported on the HS 200 form
• Notarized signature page is required
• Submit the “Acknowledgement” page from the Notary Public, if applicable​