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
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Adult Day Center Application Packet 2022 -- Updated 02/03/22
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Ambulatory Surgical Center Application Packet -- Updated 10/01/21
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Ambulatory Surgical Center Certification Packet -- Updated 12/29/2011
- Medicare Certification is voluntary
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Assisted Living Community Application Packet 2022 -- Updated 05/18/22
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Clinical Laboratory Licensure Application Packet and CLIA Certification Instructions -- Updated 01/31/17
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Community Living Arrangement Application Packet 2022 - Updated 02/03/22
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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 10/07/21
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End Stage Renal Disease (ESRD) Application Packet -- Updated 10/01/21
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Home Health Agency Application Packet -- Updated 10/01/21
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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 10/14/21
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Hospice Licensure Application Packet -- Updated 10/01/21
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Narcotic Treatment Program Packet - Updated 10/7/2019
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Nursing Home Application Packet -- Updated 10/01/21
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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 2022 -- Updated 05/18/22
- Training now available for this application packet. Click here to register
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Private Home Care Provider Application Packet -- Updated 03/22/22
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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
- 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
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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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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
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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