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 
  

Facility Information Sheet

Each individual must complete and submit the Facility Information Sheet for each facility and/or agency with which the individual has a current or past relationship within the last three years. This sheet must also include any facilities licensed by the California Department of Social Services. The following must be completed for each facility and/or agency:

• Facility name
• Facility address
• Type of facility
• Type of business entity (include EIN Number)
• Individual’s nature of involvement
• Individual’s dates of involvement

Professional Licenses​

• An active registered medical license is required for the Medical Director
• Provide a printout of the current license from the Department of Consumer Affairs (https://search.dca.ca.gov/)