Licensing Compliance Summary

This is a Licensing Compliance Summary template document prepared for the California Department of Corrections and Rehabilitation (CDCR), California Correctional Health Care Services, for Staff Medical Monitoring Services. The document serves as a standardized form for contractors and subcontractors to document their licensing and credential compliance across multiple facility locations. The sample demonstrates how contractors must list all clinic locations, mobile clinics, and laboratory facilities where services will be provided, along with the credentials of employed physicians and surgeons. The form requires submission of three categories of licenses and certifications: California Medical Board Physician and Surgeon Licenses, U.S. Department of Health and Human Services Clinical Laboratory Improvement Amendments (CLIA) Certificates, and California Department of Health Services Laboratory Field Services (LFS) Clinical Laboratory Licenses. The sample data illustrates a multi-location contractor (ABC Medical Group, Inc.) operating from a headquarters location in Bakersfield, California, along with multiple subcontractors and additional service locations throughout California, including Sacramento, Lancaster, Chowchilla, El Cajon, Manteca, Delano, and Greenbrae. Each location entry includes the facility type, supervising physician name, license and certificate numbers, expiration dates, and the corresponding CDCR institution or facility acronym where services will be provided.

The document requires all licenses and certifications to include expiration dates to ensure ongoing compliance with state and federal medical licensing requirements. Laboratory facilities need only CLIA Certificates and LFS Clinical Laboratory Licenses, while clinic and mobile clinic locations must include physician licenses alongside the laboratory certifications. The form permits additional pages to accommodate contractors with multiple locations or numerous subcontractors. This compliance summary serves as a critical component of contract administration, allowing CDCR to verify that all medical service providers maintain current, valid credentials throughout the contract performance period. The template establishes clear documentation standards for tracking licensing compliance across the healthcare delivery network supporting correctional health services.