Cover Letter

Letter on company letterhead with the following information:

• License number
  

• Facility name and address
  

• Facility ID number (if known)
  

• Brief description of request
  

• Include previous and proposed/new name
  

• Applicant Contact Informat​ion (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​​​​​​
  

​Board Resolution

Submit a Board Resolution approving name change

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, if applicable​

Medicare General Enrollment Health Care Provider/Supplier Application

• This application is from the Federal Department of Health and Human Services

• ​​The completed application should be mailed directly to the appropriate fiscal intermediary​