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HEALTH CARE FACILITY LICENSING AND CERTIFICATION​​​​​​

 Contact Us

Phone: (916) 552-8632
Email: CAB@cdph.ca.gov

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

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

Rehabilitation 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
  • Contact information (name, title, phone number, and
    email 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 (https://www.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 
HS 200 (PDF, 1.5MB)

Licensure & Certification Application

[Health and Safety Code (HSC) section 1212(a)]

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
​Board Resolution 
Board Resolution

[HSC section 1212(a)]

Submit a Board Resolution approving name change

HS 309 1st Page (PDF) 

Administrative Organization

[HSC section 1212(a)]

Along with the HS 309, the following supporting documents according to organizational type must be submitted:

​Supporting Documents 
Corporation
  • Filing Statement from the Secretary of State
  • Articles of Incorporation
  • By-Laws
  • List of Board of Directors (only if additional space is needed to input all board of directors)

Tip

  • Page 1, item 3 — The incorporation date is located in the top right corner of the Articles of Incorporation
​Supporting Documents 

​Limited Liability Company (LLC)
  • Filing Statement from the Secretary of State
  • Articles of Organization
  • Operating Agreement
  • List of Managing Members (only if additional space is needed to input all managing members)​
HS 309 2nd Page (PDF) 
Organizational Structure

Only complete fields that are applicable to applicant’s entity type

Tip

  • Page 2, item 1 — Health care districts will fill in the circle for other
​Supporting Documents

Public Agency 

Copy of signed Resolution

​Supporting Documents 

Partnership

Copy of signed Partnership Agreement

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