Cover Letter​

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)​
  
• 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
  

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

• Submit a Certificate of Occupancy
• This is not applicable if there were alterations or repairs to existing buildings performed or conversion of space
  

F.1 – 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

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)
• Individual’s nature of involvement
• Individual’s dates of involvement
  

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

Only complete Section V

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

Complete, sign and date

Tips​

• 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