Forms and Supporting Documentāsāā
| Additional Instructions
(Each form listed also has instructions on the form)
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Cover Letter
| Cover Letter Letter on company letterhead with the following information: - License number
- Facility name and address
- Facility 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
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HS 200 (PDF, 1.5MB)
| Licensure & Certification Application Tip - Attachment 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 āā
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Supporting Documents
| B.3 ā Organizational Chart ā Owner Type [42 Code of Federal Regulation (CFR) section 491.7(b)] Submit an organizational chart if the owner is nonprofit corporation, limited liability company (LLC), or general partnership. The organizational chart needs to display the following: - 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 individualsāā
- Parent company of applicant, if applicable, and all the licensed agencies/facilities it is operating - see B.6
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HS 215A (PDF)
| Applicant Individual Information The form 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
Tips - Section B ā List applicantās legal name, nature of involvement to the facility, date of birth, driverās license or state-issued identification number and expiration date, social security number
- 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
- Section F ā If answering yes to any question in this section, complete and attach the facility information sheet (section H)
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Supporting Documents
| 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 involvementā
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HS 309 (PDF)
| Administrative Organization Page 2: Only complete fields that are applicable to applicantās entity typeā
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