Renewal License Application For A Health Care Institution Page 4

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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
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

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