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HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Ambulatory Surger​y Center

Report of Change Application Checklist for Change of Governing Board

The following is a list of application forms and supporting documents required for a complete application packet. Failure to include each of the forms and documents will delay processing.

Checklist and Instructions - P​lease submit your documents in this order

Required Documents for a Change of Governi​ng Board 

​Forms and Supporting Documents​​​​​​​

​​Additional Instructions

(​​​Each form listed also has instructions on the form)​​

​Cover Letter​

Cover Letter​​

Letter on company letterhead with the following information:

  • Facility name and address

  • Facility ID number (if known)

  • Brief description of request

  • ​​​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

​HS 309 1st P​age (PDF) 

Administrative Organization

Along with the HS 309, the following supporting documents according to organizational type must be submitted

​Supporting Documents

Corporation

  • Filing Statement from the Secretary of State

  • Articles of Incorporation

  • By-Laws

  • List of Board of Directors (only if additional space is needed to input all board of directors)

Tip

  • Page 1, item 3 — The incorporation date is located in the top right corner of the applicant Articles of Incorporation

Supporting Documents

Limited Liability Company (LLC)

  • Filing Statement from the Secretary of State

  • Articles of Organization

  • Operating Agreement

  • List of Managing Members (only if additional space is needed to input all managing members)

Supporting Documents

Organizational Structure

Only complete fields that are applicable to applicant’s entity type

Tip

  • Page 2, item 1 — Health care districts will fill in the circle for other

Supporting Documents

Public Agency

Copy of signed Resolution

Supporting Documents​

Partnership

Copy of signed Partnership Agreement

​

Required Documents for Medi-Cal Providers Only

Forms and Supporting Documents​​​

Additional Instructions

(Each form listed also has instructions on the form)​


​

Licensure & Certification Application

Tip

  • Attachment F-1 — 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 

Supporting Documents

B.3 – Organizational Chart – Owner Type

Submit an organizational chart if the owner is a for profit corporation, nonprofit corporation, limited liability company (LLC), or general partnership. The organizational chart needs to display the following:

  • Applicant’s owners, including ownership percentages, Tax IDs/EINs and all directors, board members, corporate officers, LLC members/managers, and/or partners

  • Parent company of applicant, if applicable, and all the licensed agencies/facilities they are operating - see B.6

Self-Contained Letter

Self-Contained Letter

[HSC section 1765.150(b)]

  • Submit a letter or statement on cover letter verifying the mobile unit is self-contained

  • If the mobile unit is not self-contained, HCAI approval is only required if the utility hookups originate or pass through any general acute care hospital building

​HS 215A​ (PDF)​ 

Applicant Individual Information

[Title 42 Code of Federal Regulations (42 CFR) section 455 Subpart B]

Sections A, B, C, and G must be completed and signed for the following individual(s):

  • Directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization

Tip

  • Section B – List applicant’s legal name, nature of involvement to the facility, date of birth, driver’s license or state-issued identification number and expiration date, social security number​


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