End-Stage Renal Disease
Report of Change Application Checklist for Change of Property Owner
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 Property Owner
Forms and Suppāorting 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 ID number (if known)
- Brief description of request
- Contact information (name, title, phone number, and
email 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)
- Signature
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HS 200 (PDF, 1.5MB)
| Licensure & Certification Application 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
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Supporting Documents
| D.1 ā Control of Property Submit a copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licenseeā
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