Renewal License Application For A Health Care Institution Page 5

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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
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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