Follow the steps to effectively complete your application form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the general information section, which includes your agency type and legal agency name. Make sure to specify the type of application—initial or other changes.
3. Enter the trading name (doing business as) if applicable, followed by your e-mail address, phone number, business address, and mailing address if different.
4. Complete the ownership section by indicating your business organization type (sole proprietorship, partnership, LLC, or corporation) and providing the names and addresses of owners with a 2% or greater ownership.
5. Answer the background questions regarding licenses, ownership of health care facilities, and compliance with civil rights laws.
6. If you have employees, complete the workers' compensation section and attach the necessary documentation.
7. Provide details specific to your type of facility—whether it’s an ambulatory surgery center, birthing center, or other specified type—ensuring to fill out all subsections related to operations and services.
8. Check applicable boxes regarding past legal issues or accreditation details, and provide the names of relevant medical directors and agency personnel.
9. Carefully review and complete the affidavit section, ensuring all declarations are accurate. Provide your signature and the date.
10. Finally, if applicable, fill in details for any branch offices and ensure all information is accurate before submitting.
11. Once completed, save your changes and use the options to download, print, or share the form as required.

Complete your MD DHMH AC.APP.1.0 application online today for a smooth licensure process.