HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Primary Care Clinic - Affiliate Mobile

Report of Change Application Checklist for Change of Governing Board

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 Governing Board

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
Facility 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

HS 200 (PDF, 1.5MB)

Licensure & Certification Application

[Title 22 California Code of Regulation (CCR) section 75021]

Tip:

Attachment F-1 — 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

Supporting Documents

B.3 – Organizational Chart – Owner Type

Submit an organizational chart for the nonprofit corporation. The organizational chart needs to display the following:

Applicant’s, directors, board members, and corporate officers

Note: Submit the HS 215A form for each of these individuals if different from parent clinic

HS 215A (PDF)

Applicant Individual Information

[22 CCR sections 75022, 75025] [Health and Safety Code (HSC) sections 1212, 1218.1]

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

Tips:

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
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 E; however, the resume must contain all required information requested in section E
Section F — If answering yes to any question in this section, complete and attach the facility information sheet (section H)

Supporting Documents

Facility Information Sheet

Each individual (except for the Administrator) must complete and submit the Facility Information Sheet for each facility and/or agency with which the individual has a current or past relationship within the last three years. This sheet must also include any facilities licensed by the California Department of Social Services. The following must be completed for each facility and/or agency:

Facility name
Facility address
Type of facility
Type of business entity (include EIN Number)
Individual’s nature of involvement
Individual’s dates of involvement

HS 309 Page 1 (PDF)

Administrative Organization

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

Supporting Documents

Corporation

[HSC section 1218.1]

Filing Statement from the Secretary of State
Articles of Incorporation
By-Laws
List of Board of Directors (only if additional space is needed to input all board of directors)

Tip:

Page 1, item 3 — The incorporation date is located in the top right corner of the Articles of Incorporation

Supporting Documents

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)

HS 309 Page 2 (PDF)

Organizational Structure

Only complete fields that are applicable to applicant’s entity type

Tip: