Cover Letter

Letter on company letterhead with the following information:

• Facility name and 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
  

B.3 – Non-Profit Status – Owner Type

Submit a copy of the IRS Tax Exempt Determination Letter showing the non-profit 501(c)(3) status. (If applicable)

B.6 – Organizational Chart

Applicant Individual Information

[42 CFR section 420.206, 485.904(b)(1), 485.918(a)]​

This form must be completed and signed for the following individuals:

• Administrator of the facility
• Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization
• Owners, directors, board members, corporate officers, LLC members/managers, and partners of the parent, grandparent, great grandparent, and etc. organization, if applicable
• Each individual having a beneficial interest of exceeding five percent or more in the applicant organization and/or parent, grandparent, great grandparent, and etc. organization 

• Page 2, section B — The date of birth is an identifier, as several people may have the same name. This will ensure that each individual is associated with the correct facility or entity
• Page 5, 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
• Page 7, section F — If answering yes to any question in this section, complete Section H: Facility Information Sheet

Resume

A resume is required for the Administrator

Corporation

• Filing Statement from the Secretary of State
  
• Articles of Incorporation
  
• By-Laws 
  
• List of Board of Directors (only if additional space is needed to input all board of directors)
  

• Page 1, item 3 — The incorporation date is located in the top right corner of the applicant Articles of Incorporation
  

Organizational Structure

Only complete fields that are applicable to applicant's entity type

• This application is from the Federal Department of Health and Human Services
• The completed application should be mailed directly to the appropriate ​fiscal intermediary​
  

Assurance of Compliance​

• The Office of Civil Rights (OCR) online portal is: Office for Civil Rights (https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf)
• Once the online submission is completed, an electronic notification from OCR stating the Assurance of Compliance form was submitted successfully will be received by the applicant
• Submit a copy of this notification