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hEALTH CARE FACILITY LICENSING AND CERTIFICATION

Psychology Clinic

Report of Change Application Checklist for Change of Name

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 Change of Name

Forms and Supporting Documents​

Additional Instructions

(Each form listed also has instructions on the form)

Cover Letter

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

  • Include previous and proposed/new name

  • Previous and proposed/new name

  • ​​Applicant Contact Information (name, title, phone number, invoice contact email address, applicant contact email address)

    • The Department will use the invoice contact email address to invoice the application fee

    • The Department will use the applicant contact email address to send all application correspondence

  • ​General Contact Information (name, title, phone number, fax, email address, and alternative contact information)

    • The Department will use this information to contact the facility for day-to-day business

  • Emergency Contact Information (name, phone number, fax, email address, alternate email, 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 

  • ​​All Facility Letter Contact Information (name, phone number, fax, and ​email address)

    • The Department will use this information to send All Facility Letters

  • ​​Facility Contact (Public Use) Information (phone number, fax, email address, and website address)

    • The Department will use this information to store facility contact information for the public

  • ​Privacy Officer Contact Information (name, title, mailing address, phone number, and email address)

    • The Department will use this information to correspond with the facility’s Privacy/Compliance Officer regarding medical breach incidents​

  • Signature​​​
HS 200 (PDF, 1.5MB)​

Licensure & Certification Application

[Title 22 California Code of Regulation (CCR) section 75311] [Health and Safety Code (HSC) section 1212]

Tip:

  • Attachment F-1 — If the current or proposed facility, agency, or clinic is applying for Medi-Cal certification, complete Attachment F-1: Subcontractor Information and Significant Business Transactions 
Supporting Documents

Board Resolution

Submit a Board Resolution approving name change
Supporting Documents​

Restated Articles of Incorporation

Applies only to a licensee or parent company name change​​
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