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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health



​Primary Care Clinic

Supplemental Documents Help


 

The following table denoted by the “X” in that field identifies required additional supplemental documents to be submitted with the application package. If the field is blank, the additional documentation is not required to be submitted.

Supplemental Documents​PCC - InitialPCC - CHOW​PCC - Mobile​PCC - Mobile CHOW​Affiliate​Affiliate CHOW​Affiliate Mobile​Affiliate Mobile CHOW​Consoldtd License​Consoldtd Mobile​
​Copy of the Internal Revenue Service 501(c)(3) determination letter required for all nonprofit corporations
[22CCR section 75022(a)(3)]
​X​X​X​X
​Copy of “Purchase Agreement” or “Operating Transfer Agreement”​X​X​X​X
​A letter from the prospective licensee to CDPH stating where the stored patient medical records will be maintained and that the records will be made available to the previous licensee.[22 CCR section 75021(3), 75055(e)]​X​X​X​X

​For newly constructed or remodeled building - Written certification from

  1. California licensed architect, or
  2. local building authority that:
  • The building complies with Title 24 and OSHPD 3 building requirements.
    • Building Code
    • Electrical Code
    • Fire Code
    • Mechanical Code
    • Plumbing Code, or
  • Certification form for Clinic and Freestanding Outpatient Clinic Services of a Hospital (CDPH 270), or
  • Plan of Modernization approved by the OSHPD

[HSC section 1217, 1218.1,1226.3]

​X​X​X​X
​Copy of vehicle registration, including ID, type and manufacturer [HSC section 1765.120(a)]​XX​​X​X​X
​Copy of the Department of Housing & Community Development (HCD)
  • “Inspection Approval” or
  • HCD’s “insignia”

[HSC section 1765.120(b)]

​X​X​X​X​X
​If the mobile unit is not self-contained, OSHPD approval is required if the utility hookups originate or pass through any general acute care hospital building​X​X​X​X​X
​If the mobile unit is self-contained, submit a letter verifying that the mobile unit is self-contained [HSC section 1765.150(b); 1765.155(a)]​X​X​X​X​X
​Submit a written statement from the local planning/zoning agency, if you believe that the local planning/zoning approval is not required for a particular mobile clinic [HSC section 1765.150(e), 1765.155(a)] ​X​XX​X​

 

Supplemental Documents​PCC - InitialPCC - CHOW​PCC - Mobile​PCC - Mobile CHOW​Affiliate​Affiliate CHOW​Affiliate Mobile​Affiliate Mobile CHOW​Consoldtd License​Consoldtd Mobile​
​Submit a written statement from the local fire agency, if you believe that the STD 850 (Fire Safety Inspection Request) is not required for a particular mobile clinic [HSC section 1765.155(a)]​XX​

​Provide organizational charts that reflect:

  1.  The parent and affiliate clinics’ corporate officers are the same.
  2. The parent and affiliate clinics are owned and operated by the same nonprofit organization with the same board of directors.
  3. The parent and affiliate clinics have the same medical director or directors.
X​XX​X​​X
​Written statement that the parent and affiliate clinics have the same medical policies, procedures, protocols, and standards.X​​XX​X​

​Provide organizational charts that reflect:

  • Other licensed agency/facility that the applicant owns, leases, manages or operates including agency/facility/clinics out-of-state and community care facilities.
​XX​​X

​Written statement that the PCC is in compliance with the following criteria:

  1. There is a single governing body for all the facilities maintained and operated by the licensee.
  2. There is a single administration for all the facilities maintained and operated by the licensee.
  3. There is a single medical director for all the facilities maintained and operated by the licensee, with a single set of bylaws, rules, and regulations.

[HSC section 1212(d)]

Sample Memo

​XX​

​Provide organizational charts that reflect:

  1. Single governing body, which includes the board of directors, for all the facilities operated and maintained by the licensee.
  2. Single administration for all the facilities operated and maintained by the licensee.
  3. Single medical director for all the facilities operated and maintained by the licensee.

[HSC section 1212(d)]

​X​X

​Written notification identifying:

  1. The name and address of the licensee’s corporation administrative office.
  2. The name and contact information for the corporation’s chief executive officer or executive director.
  3. The name and address of the additional physical plant.
  4. Provide the following:
​XX​
​A copy of any document confirming the corporation’s authority to control the additional physical plant. (examples: a lease or purchase agreement, grant deed, bill of sale, sublease, rental agreement, or memorandum of understanding between the owner of the property and the proposed licensee).​X​X

 

 



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