HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Primary Care Clinic - Affiliate

Report of Change Application Checklist for Change of Service

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 Service (Basic Service)

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

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
Days and hours of operation
Locations serviced by mobile unit (if mobile)

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

Required Documents for a Change of Service (Special Service or Construction/Remodel)

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
Cover Letter	Cover Letter (see cover letter requirements)
HS 200 (PDF, 1.5MB)	Licensure & Certification Application [Title 22 California Code of Regulation (CCR) section 75021(2)] [Health and Safety Code (HSC) sections 1203 & 1212(b)(1)] 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	A. 10 - California Department of Health Care Access and Information (HCAI) and/or Certificate of Occupancy For a newly licensed, constructed, or remodeled building, the following is required: Title 24 compliance (OSHPD 3 Standards) - a California licensed architect or the local building authority must provide written certification of Title 24 compliance (OSHPD 3 Standards) stating the building meets the current applicable codes and the following building requirements: California Building Code (CBC) California Fire Code (CFC) California Electrical Code (CEC) California Mechanical Code (CMC) California Plumbing Code (CPC) California Administrative Code (CAC) CDPH 270: Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital, is an acceptable form to certify the facility conforms to current applicable Title 24 (OSHPD 3 Standards). This form must be signed by a California licensed architect or local building authority. Plan of Modernization: A Plan of Modernization must be approved by HCAI. This plan sets forth the proposed changes to be made to bring the applicant’s facility into substantial conformance with applicable building requirements. Certificate of Occupancy
Supporting Documents	D. 1 - Control of Property Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the licensee
Organizational Chart	Organizational Chart - Services Submit a chart including all provided services
STD 850 (PDF)	Fire Safety Inspection [Title 22 CCR section 75061] The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form

Medi-Cal Certification Documents

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

HS 269 (PDF)

Application for Medi-Cal Certification as a Primary Care Clinic Provider

Complete, sign, and date

Tips:

A Change of Ownership means the non-profit corporation owning and operating the primary care clinic does not share the same federal tax identification number as the previous number
The HS 269 form requires a National Provider Identifier number in lieu of the Medi-Cal provider number
Page 1, question 4 - the specific type of service, advice, and treatment matches any other document included with your application
Page 1, question 5 - list Medi-Cal as a source of funds