Renewal License Application For A Health Care Institution Page 6
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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
VII. SUPPLEMENTAL APPLICATION – AFFILIATED OUTPATIENT TREATMENT CENTERS ONLY
In addition to the supplemental application requirements in A.R.S. § 36-422 and 9 A.A.C. 10, Article 1, a governing
authority of an Affiliated Outpatient Treatment Center, as defined in R9-10-1901, applying for an initial or renewal
license for the Affiliated Outpatient Treatment Center shall submit the following information for each counseling facility
for which the Affiliated Outpatient Treatment Center is providing administrative support:
Name of Counseling Facility:
License No.
Street Address:
State:
Zip Code:
City:
Phone No.
Name of Administrator:
Hours of Operation:
Name of Counseling Facility:
License No.
Street Address:
State:
Zip Code:
City:
Phone No.
Name of Administrator:
Hours of Operation:
Name of Counseling Facility:
License No.
Street Address:
State:
Zip Code:
City:
Phone No.
Name of Administrator:
Hours of Operation:
Page 6
Rev. 5/23/16
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