Licensure Forms & Applications

NTP Open Enrollment Mandatory Forum - Posted 10/06/22

Schedule of Licensure Activity Fees  (PDF, 80.44 KB)  -- Posted 11/05/24

Notice: Use of the Term "Assisted Living" by Personal Care Homes  (PDF, 10.99 KB)  -- Posted 04/10/2012

Application Packets

Please visit our Provider Education Portal for GAHLES Interactive Training by process.

• Adult Day Center Application Packet  (PDF, 435.68 KB)  - Updated 01/26/26
• Ambulatory Surgical Treatment Center Application Packet  (PDF, 380.12 KB)  - Updated 01/26/26
• Assisted Living Community Application Packet  (PDF, 701.14 KB)  - Updated 09/08/25
• Birthing Center Application Packet  (PDF, 375.31 KB) - Updated 01/26/26
• Community Mental Health Center Application Packet  (PDF, 273.94 KB) - Updated 01/26/26
• Comprehensive Outpatient Rehabilitation Facility (CORF) Application Packet  (PDF, 271.66 KB)  - Updated 01/26/26
• End Stage Renal Disease (ESRD) Application Packet  (PDF, 376.05 KB)  - Updated 01/26/26
• Health Maintenance Organization Application Packet  (PDF, 255.1 KB) - Updated 09/08/25
• Home Health Agency (HHA) Application Packet  (PDF, 542.22 KB)  - Updated 09/08/25
• Hospital Program Application Packet  (PDF, 380.86 KB)  - Updated 01/26/26
• Hospice Application Packet  (PDF, 669.92 KB)  - Posted 09/08/25
• Intermediate Care Facility Individuals with Intellectual Disabilities  (PDF, 387.27 KB) - Updated 01/26/26
• Narcotic Treatment Program Initial Application Packet  (PDF, 667.79 KB)  - Posted 09/08/25
  • Narcotic Treatment Program Application Packet - App changes for providers with current permits  (PDF, 333.77 KB) - Updated 11/25/24
• Nursing Home Application Packet  (PDF, 397.63 KB)  - Updated 06126/26
• Outpatient Physical Therapy Speech Pathology  (PDF, 273.87 KB)  - Updated 01/26/26
  • Applicant must request required HCFA 359 Form
• Personal Care Home Application Packet  (PDF, 743.7 KB)  - Updated 01/26/26
• Private Home Care Provider Application Packet  (PDF, 338.15 KB)  - Updated 03/30/26
• Psychiatric Residential Treatment Facility Application Packet  (PDF, 380.75 KB) - Updated 01/26/26
• Residential Mental Health Facility Application Packet  (PDF, 380.36 KB) - Updated 01/26/26
• Rural Health Clinic Application Packet  (PDF, 274.82 KB)  - Updated 01/26/26
• Traumatic Brain Injury Application  (PDF, 388 KB)  - Updated 01/26/26
• Waiver and Variance Application Packet  (PDF, 288.02 KB) - Posted 06/26/25
• 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  (PDF, 22.81 KB)  -- Posted 03/29/12
• Community Living Arrangements  (PDF, 22.81 KB)  -- Posted 03/29/12
• Drug Abuse Treatment & Education Program  (PDF, 10.13 KB)
• ESRD Self-Reporting  (PDF, 16.13 KB)
• Hospice Self Report Form  (PDF, 31.15 KB)
• Hospital Self-Report--Patient Incident  (PDF, 108.42 KB)
• Hospital Self-Report--Other Events and Incidents  (PDF, 32.37 KB)
• Laboratory Self-Report  (PDF, 91.52 KB)  - Updated 7/13/17
• Narcotic Treatment & Education Program Self-Report  (PDF, 10.13 KB)
• Nursing Homes Incident Report  (PDF, 397.37 KB)
• Personal Care Homes Self-Report  (PDF, 22.81 KB)  -- Updated 03/29/12
• X-Ray Incident Self-Report  (PDF, 48.22 KB)  - Updated 7/6/17

Other Forms

• Community Mental Health Center  (PDF, 18.22 KB)
• End Stage Renal Disease (ESRD) Post Test  (PDF, 18.08 KB)
• Health Maintenance Organization (HMO)  (PDF, 26.08 KB) -- Updated 12/29/2011
• Lab Personnel List  (PDF, 40.53 KB)  - Updated 7/6/17
• Personal Care Homes - Physician's Medical Evaluation for Assisted Living  (PDF, 47.45 KB)
• Swing Bed Application  (PDF, 17.98 KB)
• Waiver Application   (PDF, 57.41 KB) - Updated 3/7/18