HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Contact Us

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 Administrator

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

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:

License number
Facility name and address
Licensee physical 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

Required Documents for Medi-Cal Provider Only

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

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):

Administrator of the facility

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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