PLEASE COMPLETE THIS FORM FULLY INCOMPLETE APPLICATIONS WILL BE RETURNED - cdph ca: Fill out & sign online

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out PLEASE COMPLETE THIS FORM FULLY INCOMPLETE APPLICATIONS WILL BE RETURNED - cdph ca

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open it in the editor.
Begin by entering the 'Legal Name of Firm' in the designated field. Ensure that this is the full name of your business.
If applicable, provide any 'Doing Business As' (DBA) names in the next field. If you have multiple DBAs, list them on a separate sheet.
Fill out the 'Facility Address' section with complete details including street number, city, state, and ZIP code.
Continue with the 'Mailing Address' if it differs from your facility address. This ensures all correspondence reaches you.
Complete sections for contact information such as 'Facility Telephone Number', 'E-mail Address', and '24-Hour Emergency Telephone Number'.
Indicate your type of ownership by checking the appropriate box and provide details about owners or officers if necessary.
Finally, review all entries for accuracy before signing at the bottom of the form. An incomplete application will be returned.

Start filling out your application today using our platform for free!

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Contact us

How do I complain about CDPH in California?

How to File a Complaint. Complete the complaint form or draft your own and submit via email NHAP@cdph.ca.gov or Fax Number: (916) 636-6108. Please provide the facility name and address, if applicable.

How does DOH handle complaints?

If the complaint is deemed legally sufficient, the DOH will notify you in writing and provide details of the allegations. This notification may also include a request for a written response.

What are the types of complaints reported to CDPH?

CDPH documents every complaint received in an electronic tracking system and assigns it to a health facilities evaluator supervisor, a registered nurse who classifies the allegation. Complaint categories range from resident/patient abuse and quality of care/treatment to dietary services and resident/patient rights.

How do I file a complaint against a California government agency?

For assistance in resolving a problem with a state agency, we suggest that you contact the director of the state agency, your elected representatives in the California Legislature, or a private attorney.