Skip Navigation LinksPCC-Intermittent-CHOS-Hours-Provider-Checklist


 Contact Us

Phone: (916) 552-8632

For application status requests, please include the following in your email:

  • Name of Facility or Agency
  • License or Facility/Agency # (if applicable)
  • Address
  • Facility or Provider Type
  • Date Documentation Sent
  • Contact Number​​​​​​​​​​​​​​

Primary Care Clinic - Inter​​mittent Clinic

Notification Appli​cation Checklist for Change of Service (Hours) 

The following is a list of application forms and supporting documents required for a complete application packet. Failure to include each of the forms and documents will delay processing.

Checklist and Instructions - Please submit your documents in this order

Required Documents for a Change of Service (Hours)

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions​ on the form)

Cover Letter

Cover Letter

Letter on company letterhead with a brief description of the request and the following information:

Parent Clinic

  • License number
  • Parent clinic name and address
  • Facility number (if known)
  • Contact information (name, title, phone number, and email address)

Intermittent Clinic(s)

  • Intermittent clinic name and address
  • Previous hours of operation
  • New hours of operation
  • Contact information (name, title, phone number, and email 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 (
  • 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​

Page Last Updated :