Sign California Assignment of Partnership Interest Simple

Cdph form

the licensure and certification application form HS 200 is a multi-purpose form used for all facility types that are licensed by the Department of Public Health centralized applications ranch the HS 200 is a four-page form broken up into sections application information licensee information facility agency or clinic information and property information each section is required to be filled out and the information is used by the provider to report to the centralized applications branch the type of application being submitted for processing during this instruction I will provide an overview of the information required for each section I will use the term facility when also referring to a clinic or agency I will also use the term cab when referring to the centralized applications branch let's begin page 1 you will notice on the top right corner of page 1 there is a box that states for departmental use only please do not enter any information in this box section a application information number one type of application it is really important to identify the correct type of application you are submitting there are four choices initial change of ownership or Chow management company or other change select initial if you are applying for initial licensure this means that you have never been licensed to change of ownership or Chow you are licensed and are changing ownership you would only select Chow when the proposed licensees employer identification number or ein as assigned by the IRS is different from the current owners ein if the ein has not changed the application type is considered a stop transfer management company information regarding a management company will be provided in Section C other changes select this field to report all changes to an existing licensed facility number to fill out only if you are submitting a Chow number three amount of fee enclosed please do not submit any fees with your applique once all of your application documents are received you will be contacted by cab regarding your fee number for type of change please check all that apply this is the area where you report your changes if the type of change is not listed check other and write the change please refer to the provider checklist to determine the documents required to be submitted for the type of change you have indicated number five identify your facility type only select one if you own multiple facility types you will need to submit a separate application for each number six and seven requires a yes or no answer if you are applying for Medicare or medical if yes fill out the corresponding fields number eight if you are already licensed enter the current and proposed bed or capacity for initial licensure only enter the proposed bed or capacity number nine enter a numerical age range of the clients that you currently or propose to serve number 10 provide the days and hours of operation number eleven is construction required yes or no if your facility is undergoing construction enter the anticipated starting and ending date of construction page two Section B licensee information number one licensee name as filed with the Secretary of State number two federal employers tax ID number enter the ein number assigned to you by the IRS number three owner type select one and submit your organizational chart if your owner type is b c d or e number four provide us with the licensee address including city state and zip code telephone number email address and fax number once you are licensed this is the address where the license renewal is mailed number five a if the licensee listed number one owns other facilities list them here please read five B and if applicable follow the instructions number six fill this out when the licensee listed in number one is owned by another organization here's a tip the organization must own a hundred percent of the licensee in order to be considered a parent company the organization will have their own AI in page three section C facility agency or clinic information a management agreement only applies to skilled nursing facilities or sniff a sniff intermediate care facility ICF Journal acute care hospital and adult day health centers number one a management company agreement is between the management company and the proposed licensee the proposed licensee has entered into an agreement to operate the facility on their behalf the application provides additional information regarding management companies in Section E and attachment II one number one be interim management agreement is between the current and proposed licensee the current licensee has given the proposed licensee the authority to operate the facility until the ciao is approved and a new license is issued number two proposed and current facility name when applying for initial licensure do not enter any information for the current name for any changes to the name of the facility you would enter both a current and proposed facility name number three this is the physical location of the facility please include the street address city state and zip code as well as the telephone number number four enter all fields related to the mailing address if different than the physical location listed in number three number five name a person to be in charge of the facility this is the person that cab will communicate with regarding the facility number six provide the name of the facility administrator and director of nursing or director of patient care services their date of hire professional license number if applicable and expiration date number seven is used to identify licensee ownership of five percent or more here's a tip please ensure when listing names of individuals you provide the EIN number and not the social security number number eight nine and ten applied to providers of sniffs and ICF's page four section D property information number one property ownership check one and submit evidence of controller property the evidence of control must contain the physical address of the property number two owner of record provide the name and address of the property owner or property management company the lessee is the same name and address of the licensee and is between the property owner and the licensee the licensee becomes the sub lessee when control of the property is between the owner and someone other than the licensee the licensee can sublet the property with the approval from the owner of record the applicant must submit the master lease sublease and written approval from the property owner acknowledging the sublease section e management company was discussed earlier during this instruction please refer to attachment II 1 section F requires the signature of the owner or person with the authority to submit the application the application is signed under penalty of perjury that statements on the application and accompanying attachments are correct the instructions on how to complete the HS 200 and attachment II 1 are located after page 4 of the HS 200 if you have any questions regarding how to fill out the HS 200 please call the cab main line at nine one six five five two eight six three two or submit an email to CA be at CDP HCA gov cab staff will respond to your inquiry within 48 hours thank you for your time I hope this really had