Forms and Suppoārting 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
- 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 (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)
- Signatureā
|
HS 200 (PDF, 1.5MB)
| Licensure & Certification Application [Health and Safety Code (HSC) section 1212]
Tip - Attachment F-1 ā 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
|
Supporting Documents
| B.3 ā Organizational Chart - Owner Type [HSC sections 1212, 1225(c)(3)] [Title 42 Code of Federal Regulations (42 CFR) sections 485.56, 485.709]
Submit an organizational chart if the owner is a for profit corporation, nonprofit corporation, limited liability company (LLC), or general partnership. The organizational chart needs to display the following:
- Applicant's owners, including ownership percentages, Tax IDs/EINs and all directors, board members, corporate officers, LLC, members/managers, and/or partners
Note: Submit the HS 215A form for each of these individuals
- Parent company of applicant, if applicable, and all the licensed agencies/facilities it is operating - see B.6
|
Supporting Documents
| B.6 ā Organizational Chart
[HSC sections 1212, 1225(c)(3)] [42 CFR sections 485.56, 485.709]āā
If the licensee is a subsidiary of another organization, include an organizational chart
|
Supporting Documents
| Indirect Ownership Purchase Agreement Submit an indirect ownership agreement
|
HS 215A (PDF)
| Applicant Individual Information
[HSC section 1212] [42 CFR sections 455 subpart B, 485.56]
This form must be completed and signed for the following individuals:
- Persons with ownership or control interest and managing employees
- Owners, directors, board members, corporate officers, LLC members/managers, partners, and/or trustees of the applicant organization and/or Management Company with five percent or more ownership in the facility
- āāEach individual with five percent or more direct or indirect ownership interest in the facility
āāTips
- Section B ā List applicant's legal name, nature of involvement to the facility, date of birth, driver's license or state-issued identification number and expiration date, social security number
- Section E ā Submit ten years of employment history, indicating the start and end dates of employment, job title, employer name and address. The applicant may submit a resume in lieu of completing section E; however, the resume must contain all required information requested in section E
- Section F ā If answering yes to any question in this section, complete and attach the facility information sheet (section H)
|
Supporting Documents
| Facility Information Sheet
Each individual must complete and submit the Facility Information Sheet for each facility and/or agency with which the individual has a current or past relationship within the last three years. This sheet must also include any facilities licensed by the California Department of Social Services. The following must be completed for each facility and/or agency:
- Facility name
- Facility address
- Type of facility
- Type of business entity (include EIN Number)
- Individualās nature of involvement
- Individualās dates of involvement
|
HS 309 Page 1 (PDF)
| Administrative Organization HSC sections 1212, 1225(c)(3)] [42 CFR sections 485.56, 485.709]ā
Along with the HS 309, the following supporting documents according to organizational type must be submitted:
|
āSupporting Documents
| āCorporation [HSC section 1212]
- Filing Statement from the Secretary of State (only if Articles of Incorporation are not endorsed by the CA Secretary of State)
- Articles of Incorporation (Endorsed by CA Secretary of State)
- By-Laws (Stating the size of boards)
- List of Board of Directors (only if additional space is needed to input all board of directors)
Tip
- Page 1, item 3 ā The incorporation date is located in the top right corner of the applicant Articles of Incorporation
|
Supporting Documents ā
| āLimited Liability Company (LLC)
- Filing Statement from the Secretary of State
- Articles of Organization
- Operating Agreement
- List of Board of Directors (only if additional space is needed to input all board of directors)
|
HS 309 2nd Page (PDF)
| Organizational Structure Only complete fields that are applicable to applicantās entity type Tip - Page 2, item 1 ā Health care districts will fill in the circle for other
|
āSupporting Documentsā
| Public Agency
Copy of signed Resolution
|
Supporting Documents ā
| āPartnership [HSC section 1212]
Copy of signed Partnership Agreement
|
Supporting Documents ā
| Out of State Corporations [HSC section 1212]ā
Copy of the Certificate of Qualifications from the CA Secretary of State allowing the applicant to do business in Californiaā |