HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Referral Agency

Report of Change Application Checklist for Change of Name

The following is a list of forms and supporting documents required for a complete application packet. Failure to include every form or document will delay processing or lead to denial.

Checklist and Instructions

Please submit your documents in this order and save a copy of all submitted documents for your records.

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 Indicate if the change of the name is for the Licensee and/or the Facility 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 [Health and Safety Code (HSC) section 1404.5(b)] and [Title 22 California Code of Regulations (CCR) section 74103(a)(2)] Tip: Page 1, section A, items 3(k) and 3(p) — Indicate if the change of the name is for the Licensee and/or the Facility Page 6, section B, item 6 — An organization will have its own Federal tax ID number Signature must be from the applicant (Licensee/owner), not the Administrator, unless the owner is the Administrator.
Supporting Documents	Board Resolution [22 CCR section 74105(a)(12)] Submit a copy of board resolution signed by officers and directors authorizing the facility name change and with the effective date.
Supporting Documents	Articles of Incorporation [22 CCR section 74105(a)(8)] If the Licensee name or Corporate name changes, submit a copy of amended Articles of Incorporation filed with the CA Secretary of State. Note: In case of entity conversion, submit a copy of conversion document (PDF) filed with the CA Secretary of State