Get Cdph 5000a

The Cdph 5000a form is a vital document used by hospitals in California to request temporary program flexibility during emergencies. This guide provides clear and concise instructions on how to successfully complete the form online, ensuring that users understand each component and follow the correct procedures.

Follow the steps to complete the Cdph 5000a form online

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by entering the facility name in the designated field. This should be the name of the hospital filing the request.
3. Next, input the request date, which is the date you are submitting the form.
4. Fill in the license number for your facility, ensuring accuracy for verification purposes.
5. Provide the facility phone number, followed by the full address including city, state, and zip code.
6. Enter the facility fax number where you can receive communications.
7. Designate a contact person’s name, who will be responsible for further communication regarding this request.
8. For notification of emergency tent use, check the appropriate box confirming that the hospital has obtained written approval for tent use and provide details regarding the emergency declaration.
9. In the approval request section, select all relevant requests such as tent use, space conversion, bed use, or over bedding by checking the corresponding boxes.
10. Specify the regulation for which you are requesting program flexibility, clearly indicating the nature of the request.
11. For CDPH use only, leave space for the Licensing & Certification approval staff to complete their section.
12. Provide a brief description of the problem and the rationale for requesting program flexibility, detailing the alternative methods that will be employed in the emergency.
13. Finally, ensure the form is signed by the person requesting the flexibility, including their title and printed name.
14. Upon completion, save the changes, and you have the option to download, print, or share the filled-out form.

Complete the Cdph 5000a form online to ensure your hospital can address emergencies effectively.