Renewal License Application For A Health Care Institution
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9RENEWAL 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
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