āForms andā Supportingāā Documeāāntsāā
| āāAdditional Instructions
(āāāEach form listed also has instructions on the form)ā
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āCover Letter
| Cover Letterā Letter on company letterhead with the following information: - Facility name and address
- Licensee physical address
- Facility 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)ā
- 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
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CDPH 611ā (PDF)
| Licensing and Certification for an Affiliate Primary Care Clinic Application [Title 22 California Code of Regulations (CCR) section 75021]
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āSupporting Documents
| California Department of Health Care Access and Information (HCAI) [California Building Code Section 1226 and Health and Safety Code (HSC) Section 1217, 1218.1, 1226.3] and/or Certificate of Occupancy [CCR Section 75060]
One of the three documents are required: - Written certification: 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, to certify the facility conforms to current applicable Title 24 (OSPHD 3 Standards). This form must be signed by a California licensed architect or local building authority
- Plan of Modernization: Approved by HCAI
If construction occurred and if the construction resulted in a new building or addition:
- Submit a Certificate of Occupancy
- This is not applicable if there were alterations or repairs to existing buildings performed or conversion of space
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Supporting Documents
| B.1 ā Organizational Chart ā Owner Type [HSC section 1218.1]
Submit an organizational chart for the nonprofit corporation. The organizational chart needs to display the following:
Board members, corporate officers, and new directors (corporate officers as defined in the By-Laws)
Note: Submit the HS 215A form for each new individual
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Supporting Documents
| F.1 ā Control of Property [HSC section 1218.1(10)]
Submit a signed copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed Licensee
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āHS 215A (PDF)ā
| Applicant Individual Information [HSC section 1212(a), 1218.1] [22 CCR sections 75022, 75025]ā
This form must be completed and signed for the following individuals:ā
- Administrator of the facility
- New directors, board members, and corporate officers of the applicant organization
Note: Corporate officers as defined in the By-Laws āTips
- Page 2, section B 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 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 E; however, the resume must contain all required information requested in section E
- Page 7, section F ā If answering yes to any question in this section, complete Section H: Facility Information Sheet
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Supporting Documentsā
| Facility Information Sheet Each individual (except for the Administrator) 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)
- Individualās nature of involvement
- Individualās dates of involvement
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āSupporting Documents
| āāResume [22 CCR sections 75022(a)(4), 75045(d), 75046(b)] ā
A resume is required for the Administrator
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| Fire Safety Inspection Request [HSC section 1218.1(b)(9)]
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
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