Renewal License Application For A Health Care Institution Page 7
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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
VIII. SUPPLEMENTAL APPLICATION - COLOCATION
R9-10-1031 Colocation Requirements: The following information for each proposed colocator that may share a common
area and non-treatment personnel at the collaborating outpatient treatment center. For each proposed associated licensed
provider:
Associated license provider’s name: _______________________________________________
Associated licensed provider’s license number: _____________________________________
OR
Date the associated licensed provider submitted to the department an initial license application for an outpatient
treatment center or a counseling facility license: ___________________________
Proposed Scope of Services: _________________________________________________________________________
Name of associated licensed provider’s governing authority: ________________________________________________
Will the associated licensed provider share medical records with the collaborating outpatient treatment center:
YES
NO
IF the associated licensed provider plans to share medical records with the collaborating Outpatient Treatment Center,
specify information (in the written agreement ) about which party will obtain a patient’s:
-General consent or informed consent (if applicable)
-Consent to allow a colocator access to the patient’s medical record
-Consent to allow a colocator access to the patient’s advance directives
SUBMIT a copy of the written agreement with the collaborating Outpatient Treatment Center and a floor plan that
shows each colocator's proposed treatment area and the common areas of the collaborating outpatient treatment center.
Associated license provider’s name: _______________________________________________
Associated licensed provider’s license number: _____________________________________
OR
Date the associated licensed provider submitted to the department an initial license application for an outpatient
treatment center or a counseling facility license: ___________________________
Proposed Scope of Services: _________________________________________________________________________
Name of associated licensed provider’s governing authority: _______________________________________________
Will the associated licensed provider share medical records with the collaborating outpatient treatment center?
YES
NO
IF the associated licensed provider plans to share medical records with the collaborating Outpatient Treatment Center,
specify information (in the written agreement) about which party will obtain a patient’s:
-General consent or informed consent (if applicable)
-Consent to allow a colocator access to the patient’s medical record
-Consent to allow a colocator access to the patient’s advance directives
SUBMIT a copy of the written agreement with the collaborating Outpatient Treatment Center and a floor plan that shows
each colocator's proposed treatment area and the common areas of the collaborating outpatient treatment center.
Page 7
Rev. 5/23/16
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