Forms and Supporting Documents
| Additional Instructions
(Each form listed also has instructions on the form)
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Cover Letter
| Cover Letter Letter on company letterhead with the following information: Proposed Parent Clinic Facility name and ID number (if known) Licensee physical address License number Brief description of request Statement that the PCC is in compliance with the following: There is a single governing body for all the facilities maintained and operated by the licensee There is a single administration for all the facilities maintained and operated by the licensee There is a single medical director for all the facilities maintained and operated by the licensee, with a single set of bylaws, rules and regulations
Corporation name and administrative office address Contact information for Chief Executive Officer or Executive Director, and Medical Director (name, title, and phone number) Contact information (name, title, phone number, and e-mail address) Emergency Contact Information (name, email, alternate email, phone, fax, 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/post/california-health-alert-network-cahan)
Contact Information for the Privacy Officer or Designee responsible for submitting and responding to medical breach incidents (name, title/position, mailing address, phone number, and email address) Signature
Consolidated Clinic Facility name and Identification number (if known) Hours of operation Services provided National Provider Identifier (NPI) Statement verifying the Mobile unit is self- contained
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
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Organizational Chart
| Organizational Chart – Owner Type
[Health and Safety Code (HSC) section 1212(d)]
Submit an organizational chart for the nonprofit corporation. The organizational chart needs to display the following:
Single governing body, including the board of directors, for all the facilities operated and maintained by the licensee Single administration for all the facilities operated and maintained by the licensee Single Medical Director for all the facilities operated and maintained by the licensee
Note: Submit the HS 215A form for each new individual
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HS 215A (PDF)
| Applicant Individual Information
[HSC section 1212(a)] [Title 22 California Code of Regulations (CCR) sections 75022, 75025]
This form must be completed and signed for the following individuals:
Administrator of the facility New directors, board members, and corporate officers (Chief Executive Officer (CEO), President, Chief Operations Officer (COO), Chief Financial Officer (CFO)), 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 requested in section E Page 7, section F — If answering yes to any question in this section, complete Section H: Facility Information Sheet
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HS215A 3rd Page (PDF)
| Facility Information Sheet
Each individual 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
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Supporting Documents
| Resume [HSC 1212(a)] [22 CCR sections 75022(a)(4), 75045(d), 75046(b)]
A resume is required for the Administrator
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| 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
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Vehicle Registration
| Copy of Vehicle Registration
[HSC section 1765.120(a)]
Submit copy of DMV registration documents, indicating:
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Housing & Community Development (HCD) Insignia
| Department of Housing & Community Development (HCD) Insignia
[HSC section 1765.120(b)]
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Local Planning/ Zoning Approval
| Local Planning / Zoning Approval
[HSC section 1765.155(a)]
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
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Self-Contained Letter
| Self-Contained Letter
[HSC section 1765.150(b)]
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