Application for Licensing of a Congregate Living Health Facility

The following forms and documents are required for licensure.

In addition to the forms below, you are required to submit additional documents for a change of ownership.  These documents must be submitted with your completed application.  The required information and instructions are listed on the checklist contained in the “Congregate Living Health Facility Application Request Letter and Instructional Checklist” (PDF)letter.

Congregate Living Health Facility

Required Forms to be Licensed:

• Licensure & Certification Aplication: HS 200 (PDF)
• Application Individual Information: HS 215A (PDF)
• Administrative Organization: HS 309 (PDF)
• Affidavit Regarding Patient Money: HS 400 (PDF)
• Surety Bond Verification: HS 402 (PDF)
• Transfer Agreement Between: HS 602 (PDF)
• Fire Safety Inspection Request: STD 850 (PDF)