Cover L​e​​tter

Letter on company letterhead with the following information:

• License number

• Facility name and 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​
  

​Transmittal Application for Criminal Record Clearance
(HSC section 1728.1(a)(2)(A))​

Submit the CDPH 322 form for the Administrator Designee to the address indicated on the form

Applicant Individual Information

(REVISED 7/2023)

(Title 22 California Code of Regulations (CCR) section 74661 (a)(5) & 74665) (HSC section 1728)

This form must be completed and signed for the following individuals

• Administrator Designee
  

Tips:

• Page 2, section B, item 3 — 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 D; however, the resume must contain all required information requested in section D
  

• 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​​​ Designee​