Renewal License Application For A Health Care Institution Page 9
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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
XII. SIGNATURES
1. If the applicant is an individual, the owner of the health care institution.
2. If the applicant is a partnership or corporation, two of the partnership’s or corporation’s officers.
3. If the applicant is a governmental agency, the head of the governmental agency
Title
Signature
Title
Signature
XIII
ADDITIONAL DOCUMENTATION
.
Is health care institution located in a leased facility?
YES
NO
If yes, provide a copy of the lease showing the rights and responsibilities of the parties and exclusive rights of possession of the
leased facility.
Does the licensee have an accreditation report from a nationally recognized accrediting organization?
YES
NO
If yes, SUBMIT a copy of the health care institution’s current accreditation report from a nationally recognized accrediting
organization.
Page 9
Rev. 5/23/16
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