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

Chemical Dependency Recovery Hospital

Report of Change Application Checklist for Change of Name

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.

Facility
Licensee

Checklist and Instructions - Please submit your documents in this order

Required Documents to Change the Name of the Facility or Licensee

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 Facility ID number (if known) Brief description of request. Previous and proposed/new name 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) Signature
HS 200 (PDF)	Licensure & Certification Application [Title 22 California Code of Regulations (CCR) section 79101(b)(4)] Tips Page 6, Section 6 — An organization must own 100 percent of the licensee to be considered a parent company. This parent company will have its own Employer Identification Number (EIN) Page 9, Section 5 — When listing the names of individuals with direct or indirect ownership of the facility in Section 5, provide the EIN (do not enter a Social Security number in this field)
Supporting Documents	Company Resolution Submit a copy of company resolution from Board of Directors authorizing the name change with the effective date
Supporting Documents	Articles of Incorporation/ Organization If the Licensee name or Corporate name changes, submit a copy of the Articles of incorporation

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