Cover Letter

Letter on company letterhead with the following information:

• License number
• Facility name and address
• Facility ID number (if known)
• Brief description of request
• Contact information (name, title, phone number, and e- mail 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
  

[Health and Safety Code (HSC) 1212(a)]

Submit an organizational chart, for the nonprofit corporation. The organizational chart needs to display the following:

• Applicant’s directors, board members, and corporate officers (corporate officers as defined in the By-Laws)
  Note: Submit the HS 215A form for each of these individuals
• Parent company of applicant, if applicable, and all of the licensed agencies/facilities they are operating- see B.6
  

Submit additional information, including all ownership and facility information, date and any final action

Applicant Individual Information

[HSC section 1212(a)] [22 CCR sections 75022]

This form must be completed for the following individuals:

• Administrator of the facility
• Applicant Organization
• Directors, board members, corporate officers (CEO, President, COO, CFO), LLC members/managers and partners of the applicant organization

• Parent Company (if applicable)
• Directors, board members, corporate officers, LLC members/managers, and partners of the PARENT organization

• Page 2, section B — The date of birth is an identifier, as several people may have the same name. This will ensure that each individual is associated with the correct facility or entity
• Page 5, section E — Submit ten years of employment history, indicating the start and end dates of employment, job title, employer name and address. The applicant may submit a resume in lieu of completing section E; however, the resume must contain all required information requested in section E
• Page 7, section F — If answering yes to any question in this section, complete Section H: Facility Information Sheet
  

Resume

[HSC section 1212(a)] [22 CCR section 75022(a)(4), 75045(d), 75046(b)]

A resume is required for the Administrator

• Articles of Incorporation endorsed by CA Secretary of State
• Filing Statement from CA Secretary of State (only if Articles of Organization are not endorsed by the CA Secretary of State)
• By-Laws stating size of the Board
• List of Board of Directors (only if additional space is needed to input all board of directors)

• Page 1, item 3 — The applicant can find the incorporation date located in the top right corner of the Articles of Incorporation
  

Fire Safety Inspection Request

[HSC section 1765.155(a)]

• The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form
• If the STD 850 form is not required for a particular mobile clinic, a written statement from the local fire agency must be submitted
  

Medi-Cal Provider Agreement

• Do not leave any questions blank. Enter “same” or “N/A” if not applicable
• The mailing address must be the same as reported on HS 200 form, section C, Page 8, item 3.c.1
• Notarized signature page is required
• Submit the “Acknowledgement” page from the notary public, if applicable

Notice – Effective Date of Provider Agreement

Submit one copy of the HS 328 form with original signature

• This application is from the Federal Department of Health and Human Services
• The completed application should be mailed directly to the appropriate fiscal intermediary
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