Primary Care Clinic - Affiliate 
Change of Governing Board Application Packet

A State license is required to operate as a Primary Care Clinic (PCC) - Affiliate in California. A clinic corporation on behalf of a PCC that has held a valid, unrevoked, and unsuspended license for at least the immediately preceding five years, with no demonstrated history of repeated or uncorrected violations or any regulation that pose immediate jeopardy to a patient, and that has no pending action to suspend or revoke its license may file an affiliate clinic application to establish a PCC at an additional site or a mobile health care unit, pursuant to Health and Safety Code (HSC) section 1218.1. The clinic corporation (parent clinic) that operates the existing licensed PCC may file an affiliate clinic application if all the following conditions are met:

1. The corporate officers are the same;
2. are owned and operated by the same nonprofit organization with the same board of directors; and,
3. have the same medical director or directors and medical policies, procedures, protocols, and standards.
   

To report a Change of Governing Board, you must complete the required application packet. Refer to Title 22 of the California Code of Regulations (CCR) sections 75025(a) and 75045 for information regarding a Change of Governing Board. Refer to HSC sections 1200 through 1245 for information regarding licensure requirements.

How to Apply

An applicant must submit a completed application packet to the Centralized Applications Branch (CAB). The application packet contains the required forms in one location. The provider checklist identifies the required forms and supporting documents needed to apply for licensing and certification. The provider instructions are a resource to guide you through the process. 

Please refer to the following links to get started:

• Provider Instructions (PDF)​
  
• Provider Checklist 
  

Application Packet Forms​

• HS 200 – Licensure and ​​Certification Application (PDF, 1.5MB)
• HS 2​​15A – Applicant Individual Information (PDF)
• HS 309 – Administrative Organization (PDF)
  

Where to Submit Applications

Submit completed application packets to the CAB at the address listed below. Do not send any completed application packets, forms, or supporting documents to the local CDPH, District Office.

          California Department of Public Health
          Licensing and Certification Division
          Centralized Applications Branch
          P.O. Box 997377, MS 3207
          Sacramento, CA 95899-7377