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

• Days and hours of operation

• Locations serviced by mobile unit
  

• Applicant Contact Informat​ion (name, title, phone number, invoice contact email address, applicant contact email address)

• The Department will use the invoice contact email address to invoice the application fee

• The Department will use the applicant contact email address to send all application correspondence

• General Contact Information (name, title, phone number, fax, email address, and alternative contact information)

• The Department will use this information to contact the facility for day-to-day business

• 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)

• The Department will use this information to send All Facility Letters

• Facility Contact (Public Use) Information (phone number, fax, email address, and website address)

• The Department will use this information to store facility contact information for the public

• Privacy Officer Contact Information (name, title, mailing address, phone number, and email address)

• The Department will use this information to correspond with the facility’s ​Privacy/Compliance Officer regarding medical breach incidents​

• Signature​​
  

Fire Safety Inspection Request

[HSC section 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
  

​Local Planning/Zoning Approval

[HSC section 1765.155]

• 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