HEALTH CARE FACILITY LICENSING AND CERTIFICATION

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Phone: (916) 552-8632
Email: CAB@cdph.ca.gov

For application status requests, please include the following in your email:

Application ID (if applicable)
Name of Facility or Agency
License or Facility/Agency # (if applicable)
Address
Facility or Provider Type
Date Documentation Sent
Contact Number

Ambulatory Surgery 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 - Please submit your documents in this order

Required Documents for a Change of Governing 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 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 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
HS 309 1st Page (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)
HS 200 (PDF, 1.5MB)	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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