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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health



Primary Care Clinic

Form HS 309​ - Administrative Organization/Organizational Structure

 


Please complete all items and if applicable, provide all requested supplemental documents. Do not leave any items blank. If a question does not apply, respond with “Not Applicable” or “N.A.”. The following table provides further details for the section/item # that require special instruction(s).

​Item #Section​
Corporation (Including Limited Liability Companies (LLC))
​2.

​Provide the name of the Administrator.

  • Administrator is someone who has management oversight and oversees the operations of the facility.
​5.

​Corporations/LLC must submit:

  • A copy of the Filing Statement from CA Secretary of State (only required if Articles of Incorporation are not endorsed by the CA Secretary of State), or
  • A copy of all Articles of Incorporation (endorsed by CA Secretary of State)
  • A copy of the By-Laws
​9.

​Provide the following:

  • Size of Board – Enter the number of members/managers
  • Submit a list of the Governing Board of Directors
  • Submit the HS 215A form for each individual listed under this item.
​10.

​Provide the following:

  • Enter the names of the board officers or the LLC officers/managers and indicate their role (i.e., CEO, Managing Member)
  • Submit the HS 215A form for each individual listed under this item

 



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