HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Contact Us

Phone: (916) 552-8632
Email: CAB@cdph.ca.gov

For application status requests, please include the following in your email:

Name of Facility or Agency
License or Facility/Agency # (if applicable)
Address
Facility or Provider Type
Date Documentation Sent
Contact Number

Primary Care Clinic - Affiliate Mobile

Report of Change Application Checklist for Change of Name

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 Name

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 Include previous and proposed/new name Days and hours of operation Locations serviced by mobile unit Contact information (name, title, phone number, and email 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: California Health Alert Network (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
HS 200 (PDF, 1.5MB)	Licensure & Certification Application [Title 22 California Code of Regulation (CCR) section 75021] [Health and Safety Code (HSC) section 1212 (a)(5)] 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
Board Resolution	Board Resolution Submit a Board Resolution approving name change
Restated Articles of Incorporation	Restated Articles of Incorporation Applies only to a licensee or parent company name change

Medi-Cal Certification Documents

Forms and Supporting Documents

Additional Instructions
(Each form listed also has instructions on the form)

DHCS 9098 (PDF)

Medi-Cal Provider Agreement

Do not leave any questions blank. Enter “same” or “N/A”
if not applicable
The mailing address must be the same as reported on the HS 200 form, section C, Page 3, item 4
Notarized signature page is required
Submit the “Acknowledgement” page from the notary public, if applicable

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

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