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
  

B.1 – Organizational Chart – Owner Type

[Health and Safety Code (HSC) section 1218.1]

Submit an organizational chart for the nonprofit corporation. The organizational chart needs to display the following:

• ​​​Applicant's, directors, board members, and corporate officers

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 sections 1218.1(b)(9), 1765.155(a)]

• 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
• If the STD 850 form is not required for a particular mobile clinic, a written statement from the local fire agency must be submitted
  

In addition to the above Initial application forms, a PCC – Affiliate Mobile must submit the documents requested below: [HSC sections 1765.20(a), 1765.20(b), 1765.150(b), 1765.155(a)]

• A copy of the DMV vehicle registration showing ID, type and manufacturer
• Department of Housing & Community Development (HCD) Approval
• Copy of HCD Inspection Approval, or
• Copy of HCD Insignia
• A letter verifying the mobile unit is self-contained
• If the mobile unit is not self-contained, HCAI approval is only required if the utility hookups originate or pass through any general acute care hospital building
  
• The Local Planning/Zoning approval
• Submit a copy of the Local Planning/Zoning approval
• If the Local Planning/Zoning approval is not required for a particular mobile clinic, CAB needs a written statement from the Local Planning/Zoning agency
  

Only complete Section V

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

Complete, sign and date

Tips​

• The HS 269 form require​s 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