Clinic On-Boarding Form

New Clinic Name or Clinic Move Name

New Clinic Mailing Address ( and Box #)

Form Date Field

Who is completing this form?

Provide your name, title or role

Clinic Opening Date:

Provide clinic opening date (target date to see first patients)

Clinic Licensing Information

UCSF On-Site License

Affiliate License

No License

CDPH or Regulatory Agency Site Visit

Provide information regarding CDPH or other regulatory site visit.

Scheduled with date

Scheduled with date pending

Not scheduled yet

Other regulatory agency site visits

Regulatory Affairs and HEIP Specialist

Provide which Regulatory Affairs/Licensing Specialist and HEIP Specialist handling this project.

Clinical Team Lead/Project Manager:

Provide the name, title of the clinical team lead/clinical project manager for this project.

Clinical Team Lead/Project Manager Phone:

Clinical Team Lead/Project Manager Email:

Facilities D&C Project Manager (PM)

Provide the name and title/role of the Facilities Design & Construction Project Manager.

Facilities D&C PM Phone

Provide the phone contact of the Facilities Design & Construction Project Manager.

Facilities D&C PM Email

Provide the email contact of the Facilities Design & Construction Project Manager.

Is this a new building, a move or a renovation?

Cleaning/Custodial Support Services are provided:

Who maintains Medical Equipment?

Clinical Technologies

Vendor

Other

Send me a copy of my responses