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 (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​