HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Ambulatory Surgery Center

Report of Change Application Checklist for Change of Administrator

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 Administrator

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

Cover Letter

Letter on company letterhead with the following information:

License number
Facility name and address
Licensee physical address
Facility ID number (if known)
Brief description of request
Applicant Contact Information (name, title, phone number, applicant contact email address)

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

Required Documents for Medi-Cal Provider Only

Forms and Supporting Documents

Additional Instructions

(Each form listed also has instructions on the form)

HS 215A (PDF)

Applicant Individual Information

[Title 42 Code of Federal Regulations (42 CFR) section 455 Subpart B]

Sections A, B, C, and G must be completed and signed for the following individual(s):

Administrator of the facility

Tip

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