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 Contact Us

Phone: (916) 552-8632

For application status requests, please include the following in your email:

  • Application ID (if applicable)
  • Name of Facility or Agency
  • License or Facility/Agency # (if applicable)
  • Address
  • Facility or Provider Type
  • Date Documentation Sent
  • Contact Number​​​​​​

Referral Agency​

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 In​​struc​tions - P​lease 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
  • 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: 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)
  • Sign​ature
HS 200 (PDF)
Licensure & Certification Application 

[Health and Safety Code (HSC) section 1404.5(b)] and [Title 22 California Code of Regulations (CCR) section 74103(a)(2)]


  • Page 6, section B, item 6 — An organization will have its own Federal tax ID number
​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

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