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
- 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 09/27/17
- 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 09/27/17
- 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 2/8/2019
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
- Certified Medication Aide -- Payment Coupon -- Posted 03/29/12
- 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
- Licensing Fees--Payment Coupon -- Posted 03/29/12
- Personal Care Homes - Physician's Medical Evaluation for Assisted Living
- Swing Bed Application
- Waiver Application - Updated 3/7/18