Healthcare Facilities Licensing Applications

• Abortion Facility (DPH 3312)
• Adult Day Care Facility (DPH 3287)
• Ambulatory Surgical Facility (DPH 3288)
• Birthing Center (DPH 3311)
• Body Piercing Facility (DPH 0264)
• Community Residential Care Facility (DPH 0217)
• Freestanding or Mobile Technology (DPH 3310)
• Hearing Aid Specialist:
  • Application for Examination (DPH 0220)
  • Application for License (DPH 0221)
  • (Application for Temporary Permit (DPH 0222)
• Home Health Agency (DPH 3289)
• Hospice:
  • Hospice Facility (Inpatient) (DPH 3290)
  • Hospice Facility (Outpatient) (DPH 3291)
• Hospital or Institutional General Infirmary (DPH 3292)
• Immediate Care Facility for Persons with Intellectual Disability (DPH 3321)
• In-Home Care Provider (DPH 1307)
• Midwifery:
  • Licensed Midwives (DPH 0252)
  • Midwife Apprentice (DPH 3977)
• Nursing Home (DPH 3294)
• Renal Dialysis Facility (DPH 3296)
• Residential Treatment Facility for Children and Adolescents (DPH 3297)
• Chemically Dependent or Addicted Persons Treatment Facility:
  • Outpatient Facility or Narcotic Treatment Program (Outpatient) (DPH 3295)
  • Residential Treatment Program Facility, Medical Detoxification Facility, or Social Detoxification Facility (Inpatient) (DPH 3293)
• Tattoo Facility (DPH 0234)

Other Forms (pdf)

• Hospital Perinatal Information (DPH 0281)
• Freedom of Information Request (DPH 2295)
• Request for Consideration of Cited Violation
• Request for Consultation/Assistance
• Request for Exception to Licensing Standard

For additional information, contact: Division Director Gwendolyn Thompson - 1-800-922-6735