Renewal License Application For A Health Care Institution Page 3
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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
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
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