Form DMS-744 "Application for License to Conduct a Long Term Residential Care, Adult Day Care Facility, Adult Day Health Care or Post Acute Head Injury" - Arkansas

What Is Form DMS-744?

This is a legal form that was released by the Arkansas Department of Human Services - a government authority operating within Arkansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2013;
  • The latest edition provided by the Arkansas Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DMS-744 by clicking the link below or browse more documents and templates provided by the Arkansas Department of Human Services.

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Download Form DMS-744 "Application for License to Conduct a Long Term Residential Care, Adult Day Care Facility, Adult Day Health Care or Post Acute Head Injury" - Arkansas

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ARKANSAS DEPARTMENT OF HUMAN SERVICES
OFFICE OF LONG TERM CARE
Application for License to Conduct A Long Term Residential Care, Adult Day Care Facility,
Adult Day Health Care or Post Acute Head Injury
NOTE: Before beginning this application, please read carefully the instructions on page 4.
For State Use Only
[ ] Original
[ ] Renewal
License Issued for ______________
______/_____/_____
Year
Month Day Year
License Number ______________ Vendor No. ____________________ No. Licensed For _____________________
Fee $ ___________________ License Granted Effective ___________________ License Denied ________________
Administrator, Residential and Adult Day Care _________________________________________________________
I. Name and Location
RCF Facility
ADC Facility
The undersigned hereby make application for a license to operate
ADHC Facility
Post Acute Head Injury
Name Of Facility
Address Of Facility
Street
City Or Town
County
State
Zip Code
Telephone #
Fax #
Mailing Address if different from above
II. Management and Ownership
A. The Operation or management of the facility is vested in the following:
(1)
(2) Private
(3) Non-Profit
B. If public facility, list individual who heads the governmental department having jurisdiction over the facility and
members of the Governing Board:
Name
Address
1.
2.
3.
4.
5.
DMS-744 (01/13)
Page 1 of 4
ARKANSAS DEPARTMENT OF HUMAN SERVICES
OFFICE OF LONG TERM CARE
Application for License to Conduct A Long Term Residential Care, Adult Day Care Facility,
Adult Day Health Care or Post Acute Head Injury
NOTE: Before beginning this application, please read carefully the instructions on page 4.
For State Use Only
[ ] Original
[ ] Renewal
License Issued for ______________
______/_____/_____
Year
Month Day Year
License Number ______________ Vendor No. ____________________ No. Licensed For _____________________
Fee $ ___________________ License Granted Effective ___________________ License Denied ________________
Administrator, Residential and Adult Day Care _________________________________________________________
I. Name and Location
RCF Facility
ADC Facility
The undersigned hereby make application for a license to operate
ADHC Facility
Post Acute Head Injury
Name Of Facility
Address Of Facility
Street
City Or Town
County
State
Zip Code
Telephone #
Fax #
Mailing Address if different from above
II. Management and Ownership
A. The Operation or management of the facility is vested in the following:
(1)
(2) Private
(3) Non-Profit
B. If public facility, list individual who heads the governmental department having jurisdiction over the facility and
members of the Governing Board:
Name
Address
1.
2.
3.
4.
5.
DMS-744 (01/13)
Page 1 of 4
II.
Management and Ownership (Continued)
C.
If privately owned list Ownership status
(1)
Sole Proprietorship
(2)
Partnership
(3)
Corporation
Partnership: List names and addresses of partner
Name
Address
Corporation: List names and addresses of corporate officers and percentage of individuals owning 5% or more stock
(List % of ownership by the individual’s names)
Name
Address
Non-Profit: List names and addresses of Board of Directors of the Governing Body
Name
Address
D. If ownership of building is different from the person(s) or group operating the facility, explain the
relationship including names and addresses of the owner(s).
Name
Address
III.
Licensure
A.
Number of beds
B.
If Above Total Is Different From That Which You Are Currently licensed, explain the difference
DMS-744 (01/13)
2
Page 2 of 4
III.
Licensure (Continued)
C. Name and address of facility manager/director if different from the ownership
Name
Address
State
Telephone #
IV.
Certification and Verification
State of:
County of:
I hereby certify that I have read the aforementioned Application and that all statements are true to the best of my
knowledge and belief. I am aware that any willful misrepresentation of any material fact contained on the
Application will subject me to penalties as prescribed in the State Licensing Law including, but limited to
revocation and/or suspension of this license.
I further affirm that I understand that I am eligible for a license only if the facility is in compliance with the law
and regulations thereunder, and that the Office of Long Term Care is empowered to deny, suspend, or revoke my
license on any of the grounds listed in the State Licensing Law.
___________________________________________
___________________________________________
Signature of person(s) authorized to sign in
accordance with instruction II. C
Subscribed and sworn to before me on this the _______________day of _________________________,
_________
_____________________________________________
Notary Public
(Notary Seal)
My Commission expires on _________________________
DMS-744 (01/13)
3
Page 3 of 4
INSTRUCTIONS
A. Enclosed are two (2) copies of Application for Licensure. Complete one copy and return to the Office of Long Term
Care and retain one copy for your files.
B. Please read these instructions carefully and complete this application in full. This application must be completed in
ink or typed.
C. This application is not valid unless it is notarized.
D. This license application must be signed by the following person(s) dependent upon the type of management and
ownership.
1. If the institution is public (i.e., County, City, etc.) it must be signed by the person who is head of the
governmental department having jurisdiction over it (i.e., Chairman of County Board or Chairman of
Commission) or his duly authorized representative. This authorization must be in writing, notarized and
submitted along with this application.
2. If the institution is private, it must be signed by the following dependent upon the type of business organization.
Type
Signer
Sole Proprietorship
Owner
Partnership
One of the partner
Corporation, Church, Non-Profit Association
If someone other than the above named is authorized to sign in his or her behalf, such authorization must be in
writing, notarized and attached to this application.
E. All licenses expire on midnight June 30 of the calendar year in which they are issued.
F. Application for annual renewal must be postmarked no later than March 1 of the current year in order to avoid
the payment of a penalty. This penalty shall be 10% of the facility’s licensure fee.
G. This application should be returned by certified mail to the following address:
DEPARTMENT OF HUMAN SERVICES
OFFICE OF LONG TERM CARE
P.O. BOX 8059 SLOT S408
LITTLE ROCK, AR 72203
Please make certain that you use the above listed address only. All other addresses used could cause
delays and may result in penalties being applied to your annual licensure renewal fees.
H. A check or money-order for the required licensure fee made payable to ARKANSAS DEPARTMENT OF HUMAN
must accompany this submission except for those facilities operated by the State, County or City.
SERVICES
Licensure Fee: $5.00 per bed
DMS-744 (01/13)
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