Licensure Forms & Applications

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

Schedule of Licensure Activity Fees  -- Posted 11/05/24

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

Application Packets

• Adult Day Center Application Packet  - Updated 11/25/24
• Ambulatory Surgical Treatment Center Application Packet  - Updated 11/25/24
• Ambulatory Surgical Center Certification Packet - Updated 12/29/2011
  • Medicare Certification is voluntary
• Assisted Living Community Application Packet  - Updated 11/25/24
• Birthing Center Application Packet - Updated 11/25/24
• Community Mental Health Center Application Packet - Updated 11/25/24
• Community Living Arrangement Application Packet  - Updated 11/25/24
• Comprehensive Outpatient Rehabilitation Facility (CORF) Application Packet  - Updated 11/25/24
• Drug Abuse Treatment and Education Program Application Packet - Updated 11/25/24
• End Stage Renal Disease (ESRD) Application Packet  - Updated 11/25/24
• Home Health Agency (HHA) Application Packet  - Updated 11/25/24
  • Home Health Agency (HHA) Application Packet - App changes for providers with current permit - Updated 11/25/24
• 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 Program Application Packet  - Updated 11/25/24
• Hospice Application Packet  - Updated 11/25/24
  • Hospice Application Packet - App changes for providers with current permit - Updated 11/25/24
• Intermediate Care Facility Individuals with Intellectual Disabilities - Posted 11/25/24
• Narcotic Treatment Program Initial Application Packet - Updated 11/25/24
  • Narcotic Treatment Program Application Packet - App changes for providers with current permits - Updated 11/25/24
• Nursing Home Application Packet  - Updated 11/25/24
• Outpatient Physical Therapy Speech Pathology  - Updated 11/25/24
  • Applicant must request required HCFA 359 Form
• Personal Care Home Application Packet  - Updated 11/25/24
• Private Home Care Provider Application Packet  - Updated 11/25/24
• Residential Mental Health Facility Application Packet - Updated 11/25/24
• Rural Freestanding Emergency Department Application Packet - Updated 11/25/24
• Rural Health Clinic Application Packet  - Updated 11/25/24
• Traumatic Brain Injury Application - Updated 11/25/24
• 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