Cover Letter

Letter on company letterhead with the following information:

• License number

• Facility name and ID number (if known)

• Brief description of request
  

• ​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 ​​​
  

B.3 – Organizational Chart – Owner Type

Submit an organizational chart if the owner is a For-Profit corporation, General Partnership, Limited Liability Company (LLC), Limited Liability Partnership, Limited Partnership, and Nonprofit. The organizational chart needs to display the following:

• Applicant's owners, including ownership percentages, Tax ID/EIN and all directors, board members, corporate officers, LLC, members/managers, and/or partners.

• If the licensee is a subsidiary of another organization Licensee identified in Section B.1, submit an organizational chart to display the relationship

• Parent company of applicant, if applicable, and all of the licensed agencies/facilities they are operating (see B.6)

​ Note: Submit the HS 215A form for each of these  individuals​

Applicant Individual Information (REVISED 7/2023)

[HSC section 1748(b); Standards of Quality Hospice Care (SQHC), 2003, section 6.1]

This form must be completed and signed for the following individuals:

• Owners, directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization

• Each individual having a beneficial interest of five percent or more in the applicant organization and/or parent organization​

Tips

• Page 2, section B, item 3 – The date of birth is an identifier, as several people may have the same name. This will ensure that each individual is associated with the correct facility or entity

• Page 2, section B, item 4 – Provide your Driver's License Number or a State-Issued identification Card Number. Attached a copy of the Driver's License or State-Issued Identification Card for verification.

• Page 2, section B, item 5 – The Social Security Number is an identifier, as several people may have the same name. this will ensure each individual is associated with the correct facility or entity

• Page 5, 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 D; however, the resume must contain all required information requested in section E
  

Administrative Organization

Along with the HS 309, the following supporting documents according to organizational type must be submitted:

Limited Liability Company (LLC)

• Filing Statement from the Secretary of State

• Articles of Organization

• Operating Agreement

• List of Managing Members (only if additional space is needed to input all managing members)
  

Public Agency

Copy of signed Resolution