Cove​r Letter

Letter on company letterhead with the following information:

• License number (only applicable for CHOW)

• Facility name and address

• Facility ID number (if known)
  

• Brief description of request

• Attestation that the applicant provider is located in proximity, in time and distance, to a facility with the capacity for management of obstetrical and neonatal emergencies, including the ability to provide cesarean section delivery, within 30 minutes from time of diagnosis of the emergency. Include the facility name and address with the capacity for management of obstetrical and neonatal emergencies
  

• Applicant Contact Information (name, title, phone number, applicant contact email address)

• The Department will use the applicant contact email address to send all application correspondence

• General Contact Information (name, title, phone number, fax, email address, and alternative contact information)

• The Department will use this information to contact the facility for day-to-day business

• Emergency Contact Information (name, phone number, fax, email address, alternate email, 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)

• All Facility Letter Contact Information (name, phone number, fax, and email address)

• The Department will use this information to send All Facility Letters

• Facility Contact (Public Use) Information (phone number, fax, email address, and website address)

• The Department will use this information to store facility contact information for the public

• Privacy Officer Contact Information (name, title, mailing address, phone number, and email address)

• The Department will use this information to correspond with the facility's Privacy/Compliance Officer regarding medical breach incidents​​

• Signature 

Licensure & Certification Application

[Health and Safety Code (HSC) Section 1212]

Complete the following:

Page 1, Section A

• ​Items 1, 3, 4, 5, 6​​​
  

Page 3, Section B

• Item 6:  An organization must own 100 percent of the licensee to be considered a parent company. This parent company will have its own Employer Identification Number (EIN)
  

Page 7, Section C

• Items 3 and 5

Tip:

Page 9, Section 5 - When listing the names of individuals with direct or indirect ownership of the facility in section C, provide the EIN (do not enter a Social Security number on the HS-200 form)​​

Page 17, Attachment F–1​​

​Medi-Cal Provider Agreement

• 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, page 3, section C, item 4

• Notarized signature page is required

• Submit the "Acknowledgement" page from the notary public​
  

Medicare Enrollment Application (Clinics/Group Practices)

• This application is from the Federal Department of Health and Human Services​
  

• The completed application should be mailed directly to the appropriate fiscal intermediary
  

Assurance of Compliance

• OCR's online portal is: Office for Civil Rights (https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf)

• Once the on-line submission is completed, an electronic notification from OCR stating the “Assurance of Compliance form was submitted successfully" will be sent to the applicant

• Submit a copy of this notification