HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Outpatient Physical Therapy/Speech-Language Pathology Provider

Report of Change Application Checklist for Change of Indirect Ownership

The following is a list of application forms and supporting documents required for a complete application packet. Failure to include each of the forms and documents will delay processing.

Checklist and Instructions - Please submit your documents in this order

Required Documents for a Change of Indirect Ownership

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
Cover Letter	Cover Letter Letter on company letterhead with the following information: License number Facility name and address Facility ID number (if known) Brief description of request Applicant Contact Information (name, title, phone number, applicant contact email address) 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
HS 200 (PDF, 1.5MB)	Licensure & Certification Application [Title 42 Code of Federal Regulations (CFR) section 485.709] Tip: Attachment F-1 — If the current or proposed facility, agency, or clinic is applying for Medi-Cal certification, complete Attachment F-1: Subcontractor Information and Significant Business Transactions
Supporting Documents	B.3 – Organizational Chart – Owner Type [42 CFR section 485.709(a)] 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: Applicant’s owners, including ownership percentages, Tax IDs/EINs and all directors, board members, corporate officers, LLC, members/managers, and/or partners Note: Submit the HS 215A form for each of these individuals Parent company of applicant, if applicable, and all the licensed agencies/facilities it is operating - see B.6
Supporting Documents	B.6 – Organizational Chart [42 CFR section 485.709(a)] If licensee is a subsidiary of another organization, an organizational chart must be submitted
Supporting Document	Indirect Ownership Purchase Agreement Submit a purchase, merger, transfer, or sales agreement
HS 215A (PDF)	Applicant Individual Information [42 CFR sections 455.101, 455.104, 485.709(a)] This form must be completed and signed for the following individuals: Owners, directors, board members, corporate officers (Chief Executive Officer, President, Chief Operating Officer, Chief Financial Officer), 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 Tips: Section B – List applicant’s legal name, nature of involvement to the facility, date of birth, driver’s license or state-issued identification number and expiration date, social security number 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 Section F — If answering yes to any question in this section, complete and attach the facility information sheet (section H)
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: Facility name Facility address Type of facility Type of business entity (include EIN Number) Individual’s nature of involvement Individual’s dates of involvement
HS 309 Page 1 (PDF)	Administrative Organization [42 CFR section 485.709(a)] Corporations complete page one Do not submit any attachments
HS 309 2nd Page (PDF)	Organizational Structure Only complete fields that are applicable to applicant’s entity type Tip: Page 2, item 1 — Health care districts will fill in the circle for other

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