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

• Previous and proposed/new location
  

• 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 ​​
  

A.10 – California Department of Health Care Access and Information (HCAI) and/or Certificate of Occupancy

[Title 24 California Code of Regulations (CCR) part 2 sections 111 and 1226.2] [HSC section 1226]

For a newly licensed, constructed, or remodeled building, the following is required:

• Title 24 compliance (OSHPD 3 Standards) - a California licensed architect or the local building authority must provide written certification of Title 24 compliance (OSHPD 3 Standards) stating the building meets the current applicable codes and the following building requirements:

   

• California Building Code (CBC)

• California Fire Code (CFC)

• California Electrical Code (CEC)

• California Mechanical Code (CMC)

• California Plumbing Code (CPC)

• California Administrative Code (CAC)
  

* CDPH 270: Certification Form for Clinics and Freestanding Outpatient Clinic Services of a Hospital, is an acceptable form to certify the facility conforms to current applicable Title 24 (OSHPD 3 Standards). This form must be signed by a California licensed architect or local building authority.

• Certificate of Occupancy​

Floor Plan

[HSC section 1212]

Sub​mit a floor plan that coincides with your office space

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
  

• Notarized signature page is required

• Submit the “Acknowledgement” page from the notary public, if applicable