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 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 C​are Clinic - Intermittent Clinic

Notification Application Checklist for a PCC Converting to an Intermittent Clinic 

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 PCC Conversion

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:

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 ( 
  • 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 
​Current PCC Facility License

Current PCC Facility License

Original facility license must be surrendered to the Centralized Application Branch prior to issuance of new parent clinic license listing the new intermittent clinic

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