Forms and Supportingā Documentāsāā
| Additional Instructions
(Each form listed also has instructions on the form)
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Cover Letter
| Cover Letter Letter on company letterhead with the following information: - License number
- Facility name and ID number (if known)
- Brief description of request
- Contact information (name, title, phone number, and email 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)
- Signatureā
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HS 200 (PDF, 1.5MB)
| Licensure & Certification Application (REVISED 7/2023) [Title 22 California Code of Regulation (CCR) section 74661; (Health and Safety Code (HSC) section 1728)]
Tips: - Page 3, section A, item 9 ā If the facility, agency, or clinic indicates they operate 24/7/365, complete āb" to indicate the hours of operations for the public. This information is used for surveying purposes.
- Page 3, section B, item 2 āProvide the EIN of the licensee. Do not enter a Social Security number in this field.
- Page 6, section B, item 6 ā 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)
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Supporting Documents
| B.3 ā Organizational Chart ā Owner Type Submit an organizational chart if the owner is a for profit corporation, nonprofit corporation, limited liability company (LLC), or general partnership. The organizational chart needs to display the following:ā
- Applicant's owners, including ownership percentages, Tax ID/EINs and all directors, board members, corporate officers, LLC members/managers, and/or partners
- If the licensee is a subsidiary of another organization Licensee identified in Section B.1, submit an organizational chart to display the relationship
- Parent company of applicant, if applicable, and all of the licensed agencies/facilities they are operating- see B.6
āNote: Submit the HS 215A form for the directors, board members, corporate officers, LLC members/managers, and/or partners
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HS 215A (PDF)
| Applicant Individual Information (REVISED 7/2023) [Title 22 CCR section 74661 (a)(5) & 74665, (HSC section 1728)]
This form must be completed and signed for the following individuals:
- Administrator, Administrator Designee and the Director of Patient Care Services of the facility
- Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization
- Each individual having a beneficial interest of five percent or more in the applicant organization and/or parent organizationā
Tips: - Page 2, section B, item 3 ā 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 2, section B, item 4 ā Provide your Driver's License Number or a State-Issued identification Card Number. Attached a copy of the Driver's License or State-Issued Identification Card for verification.
- Page 2, section B, item 5 ā The Social Security Number is an identifier, as several people may have the same name. this will ensure each individual is associated with the correct facility or entity [LNL1] [DS2]
- Page 5, section E ā 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 require information requested in section D
- Page 7, section Fā If answering yes to any question in this section, complete Section H, Facility Information Sheet
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Supporting Documents
| 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:ā
- Facility name
- Facility address
- Type of facility
- Type of business entity (include EIN Number)
- Individual's nature of involvement
- Individual's dates of involvement
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āāSupporting Documents
| Resume A resume is only requested for the Administrator, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization
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HS 309 Page 1 (PDF)
| Administrative Organization Along with the HS 309, the following supporting documents according to organizational type must be submitted:
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Supporting Documents
| 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)
Tip - Page 1, item 3 ā The incorporation date is located in the top right corner of the applicant Articles of Incorporation
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Supporting Documents
| Limited Liability Company (LLC) - Filing Statement from the Secretary of State
- Articles of Organization
- Operating Agreement
- List of Managing Members (only if additional space is needed to input all managing members)
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HS 309 Page 2 (PDF)
| Organizational Structure Only complete fields that are applicable to applicantās entity type
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Supporting Documents
| Public Agency Copy of signed Resolution
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Supporting Documents
| Partnership Copy of signed Partnership Agreementā
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