Forms and Supporting Documents
| Additional Instructions
(Each form listed also has instructions on the form)
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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
- Applicant Contact Information (name, title, phone number, applicant contact email address)
General Contact Information (name, title, phone number, fax, email address, and alternative contact information) Emergency Contact Information (name, phone number, fax, email address, alternate email, and phone number that will receive text messages)
All Facility Letter Contact Information (name, phone number, fax, and email address) Facility Contact (Public Use) Information (phone number, fax, email address, and website address) Privacy Officer Contact Information (name, title, mailing address, phone number, and email address) Signature
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HS 200 (PDF, 1.5MB)
| Licensure & Certification Application 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
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Supporting Documents
| B.3 – Organizational Chart – Owner Type [42 Code of Federal Regulation (CFR) section 491.7(b)] Submit an organizational chart if the owner is 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
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HS 215A (PDF)
| Applicant Individual Information
The form must be completed and signed for the following individual(s): Applicant Organization Owners, directors, board members, corporate officers, LLC members/managers, partners, and/or trustees of the applicant organization and/or Management Company
Tips:
Section B – 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 — 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 — If answering yes to any question in this section, complete and attach the facility information sheet (section H)
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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)
Individual’s nature of involvement Individual’s dates of involvement
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HS 309 (PDF)
| Administrative Organization Page 2: Only complete fields that are applicable to applicant’s entity type
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