HEALTH CARE FACILITY LICENSING AND CERTIFICATION

Primary Care Clinic - Consolidated Mobile

Report of Change Application Checklist for Change of Service

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 Service (Basic Service)

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
Days and hours of operation
Current and proposed services
Locations serviced by mobile unit
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

Required Documents for a Change of Service (Special Service)

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
Cover Letter	Cover Letter (see cover letter requirements)
HS 200 (PDF, 1.5MB)	Licensure & Certification Application [Title 22 California Code of Regulation (CCR) section 75021] [Health and Safety Code (HSC) sections 1212, 1218.1, 1765.130] 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
HS 269 (PDF)	Application for Medi-Cal Certification as a Primary Care Clinic Provider Complete, sign, and date Tips: A Change of Ownership means the non-profit corporation owning and operating the primary care clinic does not share the same federal tax identification number as the previous number The HS 269 form requires a National Provider Identifier number in lieu of the Medi-Cal provider number Page 1, question 4 - the specific type of service, advice, and treatment matches any other document included with your application Page 1, question 5 - list Medi-Cal as a source of funds

Required Documets for a Change of Service (Replacement of Consolidated Mobile Unit)

Forms and Supporting Documents	Additional Instructions (Each form listed also has instructions on the form)
Cover Letter	Cover Letter (see cover letter requirements)
HS 200 (PDF, 1.5MB)	Licensure & Certification Application [Title 22 CCR section 75021] [HSC sections 1212, 1218.1, 1765.130] 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
STD 850 (PDF)	Fire Safety Inspection Request [HSC section 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
Vehicle Registration	Copy of Vehicle Registration [HSC sections 1765.120(a), 1218.1(b)(7)] Submit copy of DMV registration documents, indicating: Vehicle Identification Number (VIN) Type of vehicle Manufacturer
Housing & Community Development Insignia	Department of Housing & Community Development (HCD) Insignia [HSC section 1765.120(b)] Department of Housing and Community Development (HCD) Approval Copy of HCD Inspection Approval, or Copy of HCD Insignia
Self-Contained Letter	Self-Contained Letter [HSC section 1765.150] A letter verifying the mobile unit is self-contained If the mobile unit is not self-contained, HCAI approval is only required if the utility hookups originate or pass through any general acute care hospital building
Local Planning/Zoning Approval	Local Planning/Zoning Approval [HSC section 1765.155] Submit a copy of the Local Planning/Zoning approval If the Local Planning/Zoning approval is not required for a particular mobile clinic, CAB needs a written statement from the Local Planning/Zoning agency