Cover Letter

Letter on company letterhead with the following information:

• License number (only applicable for CHOW)
• Facility name and 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
  

A.10 – California Department of Health Care Access and Information (HCAI) [California Building Code Section 1226 and Health and Safety Code (HSC) sections 1217, 1226.3] and/or Certificate of Occupancy [22 CCR section 75060]​

One of the three documents are required:

• Written certification: a California licensed architect or the local building authority must provide written certification of Title 24 compliance (OSHPD 3 Standards) stating the building meets the current applicable codes and the following building requirements:
   
• California Building Code (CBC)
• California Fire Code (CFC)
• California Electrical Code (CEC)
• California Mechanical Code (CMC)
• California Plumbing Code (CPC)
• California Administrative Code (CAC)
• 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 

• Plan of Modernization: Approved by HCAI

Note: Title 24 compliance does not apply to CHOWs unless there has been construction and/or remodeling.​

If construction occurred and if the construction resulted in a new building or addition:

• Submit a Certificate of Occupancy
• This is not applicable if there were alterations or repairs to existing buildings performed or conversion of space
  

[HSC section 1204(a)(1)(A)(B)] [22 CCR section 75022(a)(3)]

Submit a copy of the IRS Tax Exempt Determination Letter showing the non-profit 501(c)(3) status

B.6 – Organizational Chart

[HSC section 1212(a)]

If licensee is a subsidiary of another organization, an organizational chart must be submitted

Applicant Individual Information

[HSC section 1212(a)] [22 CCR, sections 75022]

This form must be completed and signed for the following individuals:

• Administrator of the facility
• Applicant Organization
• Directors, board members, and corporate officers of the applicant organization
  Note: Corporate officers as defined in the By- Laws
• Parent Company (if applicable)
• ​​Directors, board members, corporate officers (as defined in the By-Laws) of the PARENT organization
  

• 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
  

​​Resume

Corporation

• Filing Statement from the Secretary of State
• Articles of Incorporation
• By-Laws
• List of Board of Directors (only if additional space is needed to input all board of directors)

• Page 1, item 3 — The incorporation date is located in the top right corner of the applicant Articles of Incorporation
  

Fire Safety Inspection Request

[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.

• ​This form is not required for a CHOW unless there has been construction and/or remodeling.

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 8, item 3.c.1
• Notarized signature page is required
• Submit the “Acknowledgement” page from the notary public
  

Notice – Effective Date of Provider Agreement​

Submit one copy of the HS 328 form with original signature

Medicare General Enrollment Health Care Provider/ Supplier Application​

• This application is from the Federal Department of Health and Human Services
• The completed application should be mailed directly to the appropriate fiscal intermediary