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.
Forms and Supporting Documents
Additional Instructions
(Each form listed also has instructions on the form)
Cover LetterLetter 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
Applicant Contact Information (name, title, phone number, invoice contact email address, applicant contact email address)
The Department will use the invoice contact email address to invoice the application fee
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 215A (PDF)
Applicant Individual Information
[Title 22 California Code of Regulations (CCR) sections 79113(a)(1) and 79309]
Tips
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
Section E — Submit ten years of employment history, indicating the start and end dates of employment, job title, employer name and address. The applicant may submit a resume in lieu of completing section E; however, the resume must contain all required information requested in section E
Section F — If answering yes to any question in this section, complete and attach the facility information sheet (section H)
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
Supporting Documents
Resume
A resume is required for the Medical Director
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/)