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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 Care Clinic - Intermittent Clinic

Initial Notification Application Checklist

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 an Initial Notification

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
  • Facility name and address
  • Facility ID number (if known)
  • Contact information (name, title, phone number, and e-mail 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)

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)
  • Signatu​re
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