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

Primary Care Clinic:

• Licensee
• License number
• Facility name an​d address
• Facility ID number (if known)
• Contact information (name, title, phone number, and e-mail address)
  

Proposed Parent Clinic:

• License number
• Facility name and address
• Facility ID number (if available)
• Contact information (name, title, phone number, and email address)
• Previously approved intermittent clinic(s) (if applicable)
• 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
  

Proposed Intermittent Clinic:

• Facility name and address
• Contact information (name, title, phone number, and e-mail address)
• Hours of Operation (daily hours, including any hours closed for lunch; not to exceed maximum allowed weekly hours)
• Signature