Forms and Supporting Documents
| Additional Instructions
(Each form listed also has instructions on the form)
|
Cover Letter
| Cover Letter Letter on company letterhead with the following information:
Facility name and address Licensee physical 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)
General Contact Information (name, title, phone number, fax, email address, and alternative contact information) Emergency Contact Information (name, phone number, fax, email address, alternate email, and phone number that will receive text messages)
CAHAN (https://www.calhospitalprepare.org/cahan)
All Facility Letter Contact Information (name, phone number, fax, and email address) Facility Contact (Public Use) Information (phone number, fax, email address, and website address) Privacy Officer Contact Information (name, title, mailing address, phone number, and email address) Signature
|
CDPH 611 (PDF)
| Licensing and Certification for an Affiliate Primary Care Clinic Application [Title 22 California Code of Regulations (CCR) section 75021]
|
Supporting Documents
| B.1 – Organizational Chart – Owner Type
[Health and Safety Code (HSC) section 1218.1]
Submit an organizational chart for the nonprofit corporation. The organizational chart needs to display the following:
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] and [HSC sections 1212(a), 1218.1]
This form must be completed and signed for the following individuals:
Administrator of the facility New directors, board members, and corporate officers of the applicant organization
Tips:
Page 2, section B — 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 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 E; however, the resume must contain all required information included in section E Page 7, section F — If answering yes to any question in this section, complete Section H: Facility Information Sheet
|
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
|
Supporting Documents
| Resume [22 CCR sections 75022(a)(4), 75045(d), 75046(b)]
A resume is required for the Administrator
|
| Fire Safety Inspection Request
[HSC sections 1218.1(b)(9), 1765.155(a)]
The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form
If the STD 850 form is not required for a particular mobile clinic, a written statement from the local fire agency must be submitted
|