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 (https://www.calhospitalprepare.org/cahan)​​

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• ​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​​​​
  

​Board Resolution

[HSC section 1212(a)]

Submit a Board Resolution approving name change

​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
  

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

​Partnership

Copy of signed Partnership Agreement