Cover Letter

Letter on company letterhead with the following information:

• License number
  
• Facility name and ID number (if known)
• Brief description of request
• Previous and proposed/new location
• 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​

• Submit a list of the geographical areas (including cities, counties, and zip codes) to be served
• Submit a web-based map
• Hospice agencies must obtain prior approval of an expansion of their geographic service area from the Centers for Medicare and Medicaid Services (CMS) and the California Department of Public Health, Licensing & Certification Program ​