Get Md Dhmh 125h 2011-2025

Filling out the MD DHMH 125H form is a crucial step in obtaining a Residential Services Agency license in Maryland. This guide will provide you with clear, step-by-step instructions on how to complete this form online, ensuring a smooth application process.

Follow the steps to successfully complete the MD DHMH 125H form

1. Press the ‘Get Form’ button to access the MD DHMH 125H form online.
2. Begin by filling out the official name of your agency in the designated field, followed by your trading name (if applicable). Ensure all information is accurate.
3. Enter the agency's physical address and, if different, the mailing address. Include the county in which your agency operates.
4. Provide your business phone number, fax number, days and hours of operation, email address, and emergency/after hours contact number.
5. Indicate the name and title of the administrator and whether they identify as Mr., Ms., or Mrs., followed by their full name.
6. Select the appropriate level of care your agency will provide, such as RN supervision without medication management or complex care, and specify any complex services offered.
7. Choose the category of your agency (for-profit or non-profit) and fill out the type of ownership information, including details about sole proprietorships, partnerships, or corporations.
8. If applicable, list any branch office addresses associated with your agency, providing necessary details as requested.
9. Complete and sign the affidavit, ensuring the authorized person certifies all information is accurate and will comply with the regulations outlined.
10. Review the entire form for accuracy and completeness before saving your changes. You can then download, print, or share the completed form as needed.

Complete the MD DHMH 125H form online today to start your application process for a Residential Services Agency license.