Cover Letter

Letter on company letterhead with the following information:

• License number

• Facility name and ID number (if known)

• Brief description of request

• Attestation that the applicant provider is located in proximity, in time and distance, to a facility with the capacity for management of obstetrical and neonatal emergencies, including the ability to provide cesarean section delivery, within 30 minutes from time of diagnosis of the emergency. Include the facility name and address with the capacity for management of obstetrical and neonatal emergencies [Health and Safety Code (HSC) section 1204.3(4)(A)]
  

• Previous and proposed/new location
  

• 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)

• 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
  

​A.10 – California Department of Health Care Access and Information (HCAI) and/or Certificate of Occupancy

[California Building Code (CBC) section 1226]

[HSC section 1226]​

For a newly licensed, constructed, or remodeled building, the following is required:

• Title 24 compliance (OSHPD 3 Standards) - a California licensed architect or the local building authority must provide written certification of Title 24 compliance (OSHPD 3 Standards) stating the building meets the current applicable codes and the following building requirements:
  

• California Building Code (CBC)

• California Fire Code (CFC)

• California Electrical Code (CEC)

• California Mechanical Code (CMC)

• California Plumbing Code (CPC)

• California Administrative Code (CAC)
  

* CDPH 270: Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital, is an acceptable form to certify the facility conforms to current applicable Title 24 (OSHPD 3 Standards). This form must be signed by a California licensed architect or local building authority. ​

• ​​​​​Certificate of Occupancy 

​Fire Safety Inspection Request
 
The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form

Medi-Cal Provider Agreement

• Do not leave any questions blank. Enter “same” or “N/A” if not applicable

• The mailing address must be the same as reported on the HS 200 form, section C, Page 3, item  4
  

• Notarized signature page is required
  

• Submit the “Acknowledgement” page from the notary public