Cover Letter​​

Letter on company letterhead with the following information:

• License number
• Facil​​ity 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 He​alth 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 
  

Note: Only DHCS 9098 and cover letter are required if the request is for a change of Pay-to addres​s

Medicare Gene​ral Enrollment Health Care Provider/ Supplier Application

• This application is from the Federal Department of Health and Human Services
• The completed application should be mailed directly to the appropriate fiscal intermediary
• This document does not go to CAB​

Note: Only required for change of Mailing Address applications for Facility

• 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

Note: Only DHCS 9098 and Cover Letter are required if the request is for a change of Pay-to address