Get Request For Agency Action/license Application - Utah Department Of ... - Health Utah

This guide provides clear and instructive steps for completing the Request For Agency Action/license Application with the Utah Department of Health. Users can navigate each section efficiently, ensuring that all necessary information is accurately submitted online.

Follow the steps to complete the application with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the editor, allowing for online completion.
2. Begin by entering the identifying information. Fill in the facility or agency name, street address, and mailing address if it differs from the street address. Include the city, state, ZIP code, phone number, fax number, and facility email.
3. Next, provide details about the administrator. Enter their name, professional license status, phone number, category, and email.
4. Indicate the action requested by selecting from the following options: initial license, license renewal, change of ownership, change of administrator, change in name, change in capacity, change in management, or change in location. Be sure to meet any listed requirements for your selection.
5. For variance continuation or deemed status, identify the relevant rule and date of accreditation as needed.
6. Fill out the type of facility section. Specify the facility type (e.g., acute hospital, specialty hospital, nursing care facility) and any applicable details, such as the number of beds and emergency services offered.
7. Complete the ownership information. Indicate the type of ownership and provide the name and address for each ownership entity.
8. List the officers or owners of the facility, indicating the percentage of ownership interest for individuals with greater than 25% interest. Add additional pages if necessary.
9. Indicate the operation or management of the facility, providing the same type of ownership details as mentioned earlier.
10. Confirm that each individual listed in the ownership and management sections has attested to their legal eligibility and compliance with regulations.
11. Complete the certification of understanding section by providing your name, title, and signature, along with the date.
12. Finally, review all entered information for accuracy. Save your changes, and then you may download, print, or share the completed form as necessary.

Complete your Request For Agency Action/license Application online today.