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 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 – Organizational Chart – Owner Type

Submit an organizational chart if the owner is a For-Profit Corporation, General Partnership, Limited Liability Company (LLC), Limited Liability Partnership, Limited Partnership, and Non-Profit . The organizational chart needs to display the following:

• Applicant’s owners, including ownership percentages, Tax ID/EIN # 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 

    Note: Submit the HS 215A form for each of these individuals
  

Applicant Individual Information (REVISED 7/2023) 

[HSC section 1748(b); Standards of Quality Hospice Care (SQHC, 2003, section 5.1 - 5.3, and 6.1)]

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

• Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization

• Each individual having a beneficial interest of exceeding 5 percent or more in the applicant organization and/or parent organization
  

• 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 2, section B, item 4 – 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 – 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  

• 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

Administrative Organization

Along with the HS 309, the following supporting documents according to organizational type must be submitted:

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)
  

Public Agency

Copy of signed Resolution