Licensure Forms & Applications

Fee Notice to Currently Licensed Facilities and Providers and to Applicants for Licensure or Registration  -- Updated 09/10/21

Notice: Use of the Term "Assisted Living" by Personal Care Homes  -- Posted 04/10/2012

Application Packets

 

• Adult Day Center Initial Licensure Application Packet -- Updated 2/12/15
• Ambulatory Surgical Center Application Packet  -- Updated 03/15/12
• Ambulatory Surgical Center Certification Packet -- Updated 12/29/2011
  • Medicare Certification is voluntary
• Ambulatory Surgical Center Change of Ownership Packet--Updated  -- Updated 12/29/2011

• Ambulatory Surgical Center Relocation Packet  -- Updated 1/4/2012
• Assisted Living Communities Initial Licensure Application Packet  -- Updated 09/15/21
• Clinical Laboratory Licensure Application Packet and CLIA Certification Instructions -- Updated 01/31/17
• Community Living Arrangement (CLA) Application Packet  - Updated 09/27/17
• Comprehensive Outpatient Rehabilitation Facility (CORF) Application Packet  -- Updated 12/29/2011
• Drug Abuse Treatment and Education Program Application Packet-  -- Updated 02/08/19
• End Stage Renal Disease (ESRD) Application Packet  -- Updated 1/5/2018
• Home Health Agency Application Packet  -- Updated 12/29/2011
• Hospital Change of Ownership (CHOW) Packet  -- Updated 12/29/2011
  • Use these forms and documents only if you are undergoing a hospital Change of Ownership
• Hospital Certification Application Packet  -- Updated 12/29/2011
• Hospital Licensure Application Packet  -- Updated 12/29/2011
• Hospice Licensure Application Packet  -- Updated 06/29/2015
• Narcotic Treatment Program Packet - Updated 10/7/2019
• Nursing Home Application Packet  -- Updated 02/28/2017
• Outpatient Physical Therapy Speech Pathology
  • Applicant must request required HCFA 359 Form
• Personal Care Home Application Packet  -- Updated 09/15/21
  • Training now available for this application packet.   Click here to register
• Private Home Care Provider  - Updated 10/25/17
• Rural Freestanding Emergency Department Application Packet  -- Posted 05/20/2014
• Rural Health Clinic Application Packet
• Traumatic Brain Injury Application  -- Updated 12/29/2011
• X-Ray Application Packet -- Updated 03/04/2021
  • DCH switched to accepting applications and payments through a new web form. To upload on the new Laserfiche form, review the updated instructions tab and links to download the necessary instructions and files needed.

 

Incident Reporting Forms

 

• Assisted Living Communities  -- Posted 03/29/12
• Community Living Arrangements  -- Posted 03/29/12
• Drug Abuse Treatment & Education Program
• ESRD Self-Reporting
• Hospice Self Report Form  
• Hospital Self-Report--Patient Incident
• Hospital Self-Report--Other Events and Incidents
• Laboratory Self-Report  - Updated 7/13/17
• Narcotic Treatment & Education Program Self-Report
• Nursing Homes Incident Report
• Personal Care Homes Self-Report  -- Updated 03/29/12
• X-Ray Incident Self-Report  - Updated 7/6/17

 

Other Forms

 

• Community Mental Health Center
• End Stage Renal Disease (ESRD) Post Test
• Health Maintenance Organization (HMO) -- Updated 12/29/2011
• Lab Personnel List  - Updated 7/6/17
• Personal Care Homes - Physician's Medical Evaluation for Assisted Living
• Swing Bed Application
• Waiver Application  - Updated 3/7/18