Get Md Dhmh Ac.app.1.1 2013-2025

The MD DHMH AC.APP.1.1 form is crucial for obtaining licensure for various health care facilities in Maryland. This guide will provide you with clear, step-by-step instructions to successfully complete this form online, ensuring you meet all requirements without confusion.

Follow the steps to complete the application process effectively.

1. Press the ‘Get Form’ button to access the MD DHMH AC.APP.1.1 form and open it in your preferred online editor.
2. Begin by selecting the type of license you are applying for. You may choose from several options including ambulatory surgery center, home health agency, hospice agency, and others. Remember, only one type of agency can be applied for at a time.
3. Indicate the type of application you are filing: initial or renewal.
4. Provide the legal agency name and trading name (if different) along with your email address, phone number, and physical business address.
5. Specify the license number if applicable, then enter the name of the administrator, including their last name, first name, and middle initial.
6. Fill in the after-hours/emergency contact number and your business hours formatted in HH:MM.
7. Complete the fees section by determining the non-refundable license fee and method of payment, and indicate if a fee is attached.
8. In the ownership section, indicate your business structure (sole proprietorship, partnership, corporation) and provide additional information if needed.
9. Answer the background questions related to previous licensing actions, compliance with civil rights acts, and criminal history.
10. If applicable, provide your workers' compensation insurance information, ensuring you attach a copy if needed.
11. For ambulatory surgery centers, specify the hours of operation, any backup generators, and details of accredited statuses.
12. Complete all relevant sections for your specific agency type, including specialized questions regarding services provided, staffing, and client demographics.
13. Once you have filled out all required sections and verified all information, save your changes, and prepare to download, print, or share your completed application.

Take the next step in your compliance process by completing the MD DHMH AC.APP.1.1 form online today!