Cover Letter

Letter on company letterhead with a brief description of the request and the following information:

Current Parent Clinic:

• Facility name
• Facility address
• License number
• Facility ID number (if available)
• Contact information (name, title, phone number, and e-mail address)
  

Proposed Parent Clinic:

• Facility name
• Facility address
• License number
• Facility ID number (if available)
• Contact information (name, title, phone number, and e-mail address)
• Previously approved intermittent clinic(s) (if applicable)
• 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​
  

Intermittent Clinic:

• ​​Facility name
• Facility address
• Contact information (name, title, phone number, and e-mail address)
• Hours of Operation (daily hours, including any hours closed for lunch; not to exceed maximum allowed weekly hours)
• Signature