"Renewal License Application for a Health Care Institution" - Arizona

This "Renewal License Application for a Health Care Institution" is a Arizona-specific form released by the Arizona Department of Health Services on May 23, 2016.

Download the form by clicking the link below, fill it out by hand, and mail it as per the guidelines provided by the department or the applicable legal instructions.

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Download "Renewal License Application for a Health Care Institution" - Arizona

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RENEWAL LICENSE APPLICATION FOR A HEALTH CARE INSTITUTION
ARIZONA DEPARTMENT OF HEALTH SERVICES
PUBLIC HEALTH LICENSING SERVICES - BUREAU OF MEDICAL FACILITIES LICENSING
§
In accordance with A.R.S.
41-1030
B. An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by statute,
rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a licensing requirement or condition
unless a rule is made pursuant to that general grant of authority that specifically authorizes the requirement or condition.
D. This section may be enforced in a private civil action and relief may be awarded against the state. The court may award reasonable attorney fees,
damages and all fees associated with the license application to a party that prevails in an action against the state for a violation of this section.
E. A state employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action or dismissal
pursuant to the Agency's adopted personnel policy.
F. This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.
I. HEALTH CARE INSTITUTION INFORMATION
Name of Health Care Institution: ____________________________________
License No. ___________
Street Address: ___________________________________________________________
City: ______________________
State: ____
Zip Code: __________
Mailing Address:
City: ______________________
State: ____
Zip Code: __________
Phone No. _________________
E-mail: _________________________________________
Select one class or subclass (Listed on A.A.C. R9-10-102):
Rural general hospital
General hospital
Special hospital
Home health agency
Behavioral health inpatient facility
Unclassified health care institutions
Recovery care center
Hospice inpatient facility
Hospice service agency
Outpatient treatment center
Outpatient surgical center
Abortion clinic
____
Respite on the premises capacity:
Couns eling facility
Substance abuse transitional
facility
Number of dialysis stations: ______
Behavioral health specialized
Number of observation/stabilization chairs: _____
transitional facility
What is the health care institution’s scope of practice:
__________________________________________________________________________________________
Health care institution’s days and hours of operation (i.e. 8-5, 8:00a-5:00p):
Sun
M
T
F
T
Sat
W
Admv Hours:
______________________________________________________________________________________
Clinic Hours:
______________________________________________________________________________________
Respite Hours:
______________________________________________________________________________________
Is health care institution accredited?
YES
NO
Name of accrediting organization (must be from a nationally recognized organization):
Is health care institution requesting certification under Title XIX of the Social Security Act?
YES
NO
Page 1
Rev. 5/23/16
RENEWAL LICENSE APPLICATION FOR A HEALTH CARE INSTITUTION
ARIZONA DEPARTMENT OF HEALTH SERVICES
PUBLIC HEALTH LICENSING SERVICES - BUREAU OF MEDICAL FACILITIES LICENSING
§
In accordance with A.R.S.
41-1030
B. An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by statute,
rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a licensing requirement or condition
unless a rule is made pursuant to that general grant of authority that specifically authorizes the requirement or condition.
D. This section may be enforced in a private civil action and relief may be awarded against the state. The court may award reasonable attorney fees,
damages and all fees associated with the license application to a party that prevails in an action against the state for a violation of this section.
E. A state employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action or dismissal
pursuant to the Agency's adopted personnel policy.
F. This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.
I. HEALTH CARE INSTITUTION INFORMATION
Name of Health Care Institution: ____________________________________
License No. ___________
Street Address: ___________________________________________________________
City: ______________________
State: ____
Zip Code: __________
Mailing Address:
City: ______________________
State: ____
Zip Code: __________
Phone No. _________________
E-mail: _________________________________________
Select one class or subclass (Listed on A.A.C. R9-10-102):
Rural general hospital
General hospital
Special hospital
Home health agency
Behavioral health inpatient facility
Unclassified health care institutions
Recovery care center
Hospice inpatient facility
Hospice service agency
Outpatient treatment center
Outpatient surgical center
Abortion clinic
____
Respite on the premises capacity:
Couns eling facility
Substance abuse transitional
facility
Number of dialysis stations: ______
Behavioral health specialized
Number of observation/stabilization chairs: _____
transitional facility
What is the health care institution’s scope of practice:
__________________________________________________________________________________________
Health care institution’s days and hours of operation (i.e. 8-5, 8:00a-5:00p):
Sun
M
T
F
T
Sat
W
Admv Hours:
______________________________________________________________________________________
Clinic Hours:
______________________________________________________________________________________
Respite Hours:
______________________________________________________________________________________
Is health care institution accredited?
YES
NO
Name of accrediting organization (must be from a nationally recognized organization):
Is health care institution requesting certification under Title XIX of the Social Security Act?
YES
NO
Page 1
Rev. 5/23/16
RENEWAL LICENSE APPLICATION FOR A HEALTH CARE INSTITUTION
ARIZONA DEPARTMENT OF HEALTH SERVICES
PUBLIC HEALTH LICENSING SERVICES - BUREAU OF MEDICAL FACILITIES LICENSING
II. OWNER INFORMATION
Owner’s Name:
Street Address:
City:
State:
Zip Code:
Phone No.
Fax No
The owner is a (select one):
Sole proprietorship
Corporation
Partnership
Limited liability partnership
Governmental agency
Limited liability company
If the owner is a partnership or a limited liability partnership, the name of each partner;
If the owner is a limited liability company, the name of the designated manager or, if no manager is designated, the
names of any two members of the limited liability company;
If the owner is a corporation, the name and title of each corporate officer; or
If the owner is a governmental agency, the name and title of the individual in charge of the governmental agency or
the name of an individual in charge of the health care institution designated in writing by the individual in charge of
the governmental agency:
Name:
Title:
Title:
Name:
Title:
Name:
Has the owner or any person with 10% or more business interest in the health care institution had a
license to operate a health care institution denied, revoked, or suspended since the previous license application was
submitted?
YES
NO
If yes, indicate:
The reason for denial, revocation, or suspension:
The date of the denial, revocation, or suspension:
The name and address of the licensing agency that denied, revoked, or suspended the license or certification:
Page 2
Rev. 5/23/16
RENEWAL LICENSE APPLICATION FOR A HEALTH CARE INSTITUTION
ARIZONA DEPARTMENT OF HEALTH SERVICES
PUBLIC HEALTH LICENSING SERVICES - BUREAU OF MEDICAL FACILITIES LICENSING
Has the owner or any person with 10% or more business interest in the health care institution had a health care
professional license or certificate denied, revoked, or suspended since the previous license application was
submitted?
NO
YES
If yes, indicate:
The reason for denial, revocation, or suspension:
The date of the denial, revocation, or suspension:
The name and address of the licensing agency that denied, revoked, or suspended the license or certification:
Does the applicant agree to allow the Department to submit supplemental requests for information under
A.A.C. R9-10- 108(C)(2) ?
YES
NO
SUBMIT applicable fees required by R9-10-106. All fees are non-refundable except as provided in A.R.S. § 41-1077.
III SUPPLEMENTAL APPLICATION – HOSPITALS ONLY
If applicable, the licensed occupancy for providing observation/stabilization services to:
Individuals under 18 years of age:
Individuals 18 years of age and older:
IDENTIFY all medical staff specialties and subspecialties, ATTACH LIST to renewal license application.
Page 3
Rev. 5/23/16
RENEWAL LICENSE APPLICATION FOR A HEALTH CARE INSTITUTION
ARIZONA DEPARTMENT OF HEALTH SERVICES
PUBLIC HEALTH LICENSING SERVICES - BUREAU OF MEDICAL FACILITIES LICENSING
SUPPLEMENTAL APPLICATION – HOSPITALS ONLY (cont’d)
In addition to the supplemental application requirements above and if a hospital is requesting a single group license, authorized
in A.R.S. § 36-422(F), the following information for each satellite facility providing medical services, nursing
services, or health-related services under the single group license :
Name of Satellite Facility:
Street Address:
City:
State:
Zip Code:
Phone No.
Name of Administrator:
Hours of Operation:
Name of Satellite Facility:
Street Address:
City:
State:
Zip Code:
Phone No.
Name of Administrator:
Hours of Operation:
Name of Satellite Facility:
Street Address:
City:
State:
Zip Code:
Phone No.
Name of Administrator:
Hours of Operation:
Page 4
Rev. 5/23/16
RENEWAL LICENSE APPLICATION FOR A HEALTH CARE INSTITUTION
ARIZONA DEPARTMENT OF HEALTH SERVICES
PUBLIC HEALTH LICENSING SERVICES - BUREAU OF MEDICAL FACILITIES LICENSING
IV. SUPPLEMENTAL APPLICATION – BEHAVIORAL HEALTH INPATIENT FACILITIES ONLY
Behavioral health observation/stabilization services including the licensed occupancy requested for providing
behavioral health observation/stabilization services to individuals
Under 18 years of age
_ 18 years of age and older
Inpatient services to individuals under 18 years of age, including the licensed capacity requested
V. SUPPLEMENTAL APPLICATION – HOSPICE ONLY
For a hospice service agency:
Hours of operation for the hospice’s administrative office:
Geographic region served:
For a hospice inpatient facility, requested licensed capacity:
VI. SUPPLEMENTAL APPLICATION – HOME HEALTH AGENCIES ONLY
For a home health agency:
Name of Proposed Branch Office:
Street Address:
City:
State:
Zip Code:
Geographic region served:
Name of Proposed Branch Office:
Street Address:
City:
State:
Zip Code:
Geographic region served:
Name of Proposed Branch Office:
Street Address:
City:
State:
Zip Code:
Geographic region served:
SUBMIT to the Department a copy of a valid fingerprint clearance card issued according to A.R.S. Title 41, Chapter 12,
Article 3.1 for the applicant, if the applicant is an individual; or each individual with a 10% or greater ownership of the
business organization, if the applicant is a business organization.
Page 5
Rev. 5/23/16
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