Most forms are downloadable in Microsoft Word (word) or Adobe Acrobat (pdf) file formats. Download and save the file to your computer, complete the form, and mail to the Bureau of Health Care Quality and Compliance at the address indicated on the form.

• Health Facilities

• Medical Laboratories and Personnel

• Radiological Health Forms

Health Facilities

• Notice to those seeking certification for Medicare or Medicaid reimbursement (pdf).

►Application for Medical Facilities, Health Facilities, and other provider types (pdf)
 

►Checklist for Medical and Health Facilities (Choose the checklist for your facility type)
 

►Sample Criminal History Statement (word) (pdf) PV

►Group Home Resurvey Application (word)

Plan Review Documents

►Plan Review Application and Instructions (word) (pdf)

►Functional Plan Instructions

      Ambulatory Surgical Center (word) (pdf)

      Hospital (word) (pdf)

      Psychiatric Hospital (word) (pdf)

      Rehabilitation Hospital (word) (pdf)

      Skilled Nursing Facility (word) (pdf)

►Plan Review of Food Establishments within Health Facilities (word) (pdf) med

Medical Laboratories and Personnel Downloadable Applications

Labs

• Clinical Laboratory Improvement Amendments (CLIA) Application for Licensure (CMS-116) (pdf)

• CLIA Disclosure of Ownership & Control Interest Statement (CMS-1513) (pdf)

• Laboratory Exemption Self-Assessment Checklist (pdf)

• Laboratory Exemption Application (pdf)

• Laboratory Registration & Licensed Self-Assessment  (pdf)

• Laboratory Registration & Licensed Application (pdf)

• Licensed Laboratory Request for Off-Site Testing - Health Fairs (pdf)

Personnel

• Laboratory Director License Application (pdf)

• Clinical Laboratory Personnel Certification Guidelines (pdf)

• Clinical Laboratory Personnel Certification Application (pdf)

• Change of Name or Address Form for Clinical Laboratory Personnel (pdf)