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HEALTH CARE FACILITY LICENSING AND CERTIFICATION

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 Instruction​ - P​lease 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

  • 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 200 (PDF, 1.5MB)​

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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