Referral Agencyā
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.ā
Checklist and Instructions
Pālease submit your documents in this order and save a copy of all submitted documents for your records.
Required Documents for a Change of Name
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Forms andāāā Supporting Documentsā
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āāAdditional Instructions
(āāāEach form listed also has instructions on the form)ā
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āCover Letter
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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
- 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:
CAHANā (āwww.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
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āHS ā200 (PDF, 1.5MB)ā
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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) ā Indicate if the change of the name is for the Licensee and/or the Facility
- Page 6, section B, item 6 ā 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.
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āSupporting Documents
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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.
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āSupporting Documents
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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.ā
Note: In case of entity conversion, submit a copy of
conversion docuāmentā (PDF) filed with the CA Secretary of Stateā
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