Rehabilitation Clinics and Comprehensive Outpatient Rehabilitation Facility (CORF) Report of Change Application Checklist - Required Documents for a Change of Stock Transfer

Sep 26, 2026

Rehabilitation Clinics and Comprehensive Outpatient Rehabilitation Facility (CORF) Report of Change Application Checklist outlines the forms and supporting materials required for a complete change of stock transfer application packet. It specifies submission order and warns that omission of any required item will delay processing. The checklist provides instructions for key documents such as a cover letter with license and facility identifiers, the HS 200 licensure and certification application, organizational charts for owner and parent structures, stock purchase agreement copies, and HS 215A applicant individual information.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages5

Reading Time13 min

AccessFree to download

Required Documents for a Change of Stock Transfer

Checklist and Instructions (Submit in Order)

Cover Letter

HS 200 Licensure & Certification Application

Organizational Chart (Owner Type)

Organizational Chart (B.6)

Stock Purchase Agreement

HS 215A Applicant Individual Information

Facility Information Sheet

Administrative Organization (HS 309 1st Page)

Rehabilitation Clinics and Comprehensive Outpatient Rehabilitation Facility (CORF) Report of Change Application Checklist for Change of Stock Transfer 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 STOCK TRANSFER | Use this
space to
check if
included | 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:
• License number
• Facility name and ID number (if known)
• Brief description of request
• Contact information (name, title, phone number, and email 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/cahan](https://www.calhospitalprepare.org/cahan))
• Signature | | Use this
space to
check if
included | Forms and
supporting
documents | Additional Instructions
(Each form listed also has instructions on the form) | | --- | --- | --- | | | HS 200 | LICENSURE & CERTIFICATION APPLICATION
[Health and Safety Code (HSC) section 1212]
Tips
• Page 2, section B, item 6—An organization must own 100 percent of the licensee to be considered a parent company. This parent company will have its own Employer Identification Number (EIN)
• Page 3, section C, item 7—When listing the names of individuals with direct or indirect ownership of the facility in section C, provide the EIN (do not enter a Social Security number in this field) | | | Supporting
Documents | B.3 – ORGANIZATIONAL CHART – OWNER TYPE
[HSC section 1212 and 1225(c)(3)] [Title 42 Code of Federal Regulations (42 CFR) sections 485.56 , 485.709]
Submit an organizational chart if the owner is a for profit corporation, nonprofit corporation, limited liability company (LLC), or general partnership. The organizational chart needs to display the following:
• Applicant’s owners, including ownership percentages, Tax IDs/EINs and all directors, board members, corporate officers, LLC, members/managers, and/or partners
Note: Submit the HS 215A form for each of these individuals.
• Parent company of applicant, if applicable, and all of the licensed agencies/facilities it is operating-see B.6 | | | Supporting
Documents | B.6 – ORGANIZATIONAL CHART
[HSC section 1212 and 1225(c)(3)] [42 CFR sections 485.56 , 485.709]
If the licensee is a subsidiary of another organization, include an organizational chart | | Use this
space to
check if
included | Forms and
supporting
documents | Additional Instructions
(Each form listed also has instructions on the form) | | --- | --- | --- | | | Supporting
Documents | STOCK PURCHASE AGREEMENT
[HSC section 1212 (a)]
Copy of the signed Purchase Agreement | | | HS 215A | APPLICANT INDIVIDUAL INFORMATION
[HSC 1212] [42 CFR sections 455 subpart B , 485.56]
This form must be completed and signed for the following individuals:
• Persons with ownership or control interest and managing employees
o Owners, directors, board members, corporate officers, LLC members/managers, partners, and/or trustees of the applicant organization
and/or Management Company with five percent or more ownership in the facility
o Each individual with five percent or more direct or indirect ownership interest in th

FAQs

What happens if the required forms and supporting documents are not included?

Processing will be delayed if any required forms or supporting documents are omitted from the application packet.

What information must be included in the cover letter for a stock transfer change request?

The cover letter must be on company letterhead and include the license number, facility name and ID (if known), a brief description of the request, contact information, emergency contact information usable by the CAHAN 24/7/365, and the provider signature.

When is an organizational chart required and what should it show?

An organizational chart is required when the owner is a for-profit corporation, nonprofit corporation, LLC, or general partnership. It must show the applicant’s owners with ownership percentages and Tax IDs/EINs plus all relevant directors and officers, and include the parent company and licensed agencies/facilities it operates where applicable.

Sep 26, 2026

Uploaded by Emma Wilson