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Forms and Supporting Documents
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Additional Instructions
(Each form listed also has instructions on the form)
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Cover Letter
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Cover Letter
Letter on company letterhead with the following information:
Proposed Parent Clinic
Facility name and address
Licensee physical address License number Facility ID number (if known)
Brief description of request
Statement that the PCC is in compliance with the following:
Corporation name and administrative office address Contact information for Chief Executive Officer or Executive Director (name, title, and phone number)
Applicant Contact Information (name, title, phone number, invoice contact email address, applicant contact email address) General Contact Information (name, title, phone number, fax, email address, and alternative contact information) 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)
Facility Contact (Public Use) Information (phone number, fax, email address, and website address) Privacy Officer Contact Information (name, title, mailing address, phone number, and email address)
Signature
Consolidated Clinic
National Provider Identifier (NPI) Applicant Contact Information (name, title, phone number, invoice contact email address, applicant contact email address) General Contact Information (name, title, phone number, fax, email address, and alternative contact information) 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) Facility Contact (Public Use) Information (phone number, fax, email address, and website address) Privacy Officer Contact Information (name, title, mailing address, phone number, and email address) Signature
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HCAI and/or Certificate of Occupancy
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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 [Title 22CCR section 75060]
One of the three documents are required:
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CDPH 270: Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital, 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
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Plan
of
Modernization:
Approved
by
HCAI
If
construction
occurred
and
if
the
construction
resulted
in a new building or addition:
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Supporting Documents
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Organizational Chart – Owner Type
[HSC section 1212(d)]
Submit an organizational chart for the nonprofit corporation. The organizational chart needs to display the following:
Single governing body, including the board of directors, for all the facilities operated and maintained by the licensee Single
administration
for
all
the
facilities
operated
and maintained by the licensee
Note:
Submit
the HS
215A form
for
each
new
individual
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Control of Property
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Control of Property
[HSC section 1212(d)(4)(C)] 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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HS 215A (PDF)
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Applicant Individual Information
[HSC section 1212(a)] [22 CCR sections 75022, 75025]
This form must be completed and signed for the following individuals:
Administrator of the facility New
directors,
board
members,
and
corporate
officers
of the applicant organization
Note:
Corporate
officers
as
defined
in
the
By-Laws
Tips:
Page 2, section B — 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 — 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 — If answering yes to any question in this section, complete Section H: Facility Information Sheet
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Supporting Documents
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Facility Information Sheet
Each individual 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
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Supporting Documents
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Resume
[22 CCR sections 75022(a)(4), 75045(d), 75046(b)]
A resume is required for the Administrator
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Fire Safety Inspection Request
[HSC section 1212(d)(3)(E)] [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.
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