Licensure Forms & Applications
Fee Notice To Currently Licensed Facilities And Providers
and To Applicants Licensure or Registration
-- Posted 01/16/2014
Notice: Use of the Term "Assisted Living" by Personal Care Homes
-- Posted 04/10/2012
Application Packets
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Adult Day Center Initial Licensure Application Packet -- Updated 2/12/15
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Ambulatory Surgical Center Application Packet -- Updated 03/15/12
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Ambulatory Surgical Center Certification Packet -- Updated 12/29/2011
- Medicare Certification is voluntary
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Ambulatory Surgical Center Change of Ownership Packet--Updated -- Updated 12/29/2011
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Ambulatory Surgical Center Relocation Packet -- Updated 1/4/2012
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Assisted Living Communities Initial Licensure Application Packet -- Updated 09/27/17
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Clinical Laboratory Licensure Application Packet and CLIA Certification Instructions -- Updated 01/31/17
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Community Living Arrangement (CLA) Application Packet - Updated 09/27/17
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Comprehensive Outpatient Rehabilitation Facility (CORF) Application Packet -- Updated 12/29/2011
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Drug Abuse Treatment and Education Program Application Packet- -- Updated 02/08/19
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End Stage Renal Disease (ESRD) Application Packet -- Updated 1/5/2018
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Home Health Agency Application Packet -- Updated 12/29/2011
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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
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Hospital Certification Application Packet -- Updated 12/29/2011
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Hospital Licensure Application Packet -- Updated 12/29/2011
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Hospice Licensure Application Packet -- Updated 06/29/2015
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Narcotic Treatment Program Packet - Updated 10/7/2019
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Nursing Home Application Packet -- Updated 02/28/2017
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Outpatient Physical Therapy Speech Pathology
- Applicant must request required HCFA 359 Form
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Personal Care Home Application Packet -- Updated 09/27/17
- Training now available for this application packet. Click here to register
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Private Home Care Provider - Updated 10/25/17
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Rural Freestanding Emergency Department Application Packet -- Posted 05/20/2014
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Rural Health Clinic Application Packet
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Traumatic Brain Injury Application -- Updated 12/29/2011
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X-Ray Application Packet -- Updated 2/8/2019
Incident Reporting Forms
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Assisted Living Communities -- Posted 03/29/12
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Community Living Arrangements -- Posted 03/29/12
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Drug Abuse Treatment & Education Program
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ESRD Self-Reporting
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Hospice Self Report Form
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Hospital Self-Report--Patient Incident
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Hospital Self-Report--Other Events and Incidents
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Laboratory Self-Report - Updated 7/13/17
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Narcotic Treatment & Education Program Self-Report
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Nursing Homes Incident Report
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Personal Care Homes Self-Report -- Updated 03/29/12
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X-Ray Incident Self-Report - Updated 7/6/17
Other Forms
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Certified Medication Aide -- Payment Coupon -- Posted 03/29/12
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Community Mental Health Center
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End Stage Renal Disease (ESRD) Post Test
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Health Maintenance Organization (HMO) -- Updated 12/29/2011
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Lab Personnel List - Updated 7/6/17
- Licensing Fees--Payment Coupon -- Posted 03/29/12
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Personal Care Homes - Physician's Medical Evaluation for Assisted Living
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Swing Bed Application
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Waiver Application - Updated 3/7/18