Get De Dhss Application For Free Standing Surgical Center License 2018-2025

This guide provides step-by-step instructions for completing the DE DHSS Application For Free Standing Surgical Center License online. Whether you are a first-time applicant or renewing your license, following these instructions will help ensure a smooth process.

Follow the steps to fill out the form.

1. Click ‘Get Form’ button to obtain the form and access it within your preferred online editor.
2. In the first section, enter the legal name of the facility along with any doing business as (DBA) name.
3. Provide the complete facility address, including address line 1, address line 2 (if applicable), city, state, and zip code.
4. Fill in the details for the director, medical director, and clinical director, including their email addresses and relevant license numbers with expiration dates.
5. Complete the facility contact information by providing the name, title, email, and phone numbers, including the facility phone number.
6. Provide the emergency contact information, ensuring you include a name, contact phone number, and email, as they should be available at all times.
7. Indicate the facility type by selecting either single specialty or multi-specialty and identify the specialty if applicable.
8. Document the facility hours of operation for each day of the week.
9. Utilize the square footage requirements to state the total number of prep-recovery beds, operating rooms, prep beds, procedure rooms, and recovery beds.
10. Check each type of procedure performed at the facility and provide the number of procedures for each type conducted in the last 12 months.
11. Complete the section detailing events such as patient deaths, hospital transfers, thefts, fires, patient stays exceeding 23 hours 59 minutes, and average length of stay.
12. Indicate accreditation and deemed status information, including effective and expiration dates.
13. List any laboratory and radiology services provided, along with the names of providers.
14. Attach the required documentation, including lists of officers and governing bodies, accreditation certificate, fire safety report, annual review documentation, and emergency preparedness plan.
15. Enter the name, title, and signature of the person completing the form along with the date.
16. Ensure that all fees, including the initial application fee and annual licensure fee, are noted, and prepare your application for submission.
17. Final step: Save changes, download, print, or share the completed form as necessary.

Begin the online application process today to ensure timely submission of your documents.