Get Md Dhmh Ac.app.1.0 2018

The MD DHMH AC.APP.1.0 is a crucial form used for applying for licensure in various ambulatory care settings in Maryland. This guide provides step-by-step instructions to assist users in completing the form accurately and efficiently in an online format.

Follow the steps to complete the MD DHMH AC.APP.1.0 form online.

1. Press the ‘Get Form’ button to access the form and open it in your online editor.
2. Begin by filling in the general information section. This includes checking the type of license you are applying for, such as freestanding ambulatory surgery center, hospice care agency, or other types. Ensure you select the correct option that suits your agency.
3. Next, indicate the type of application you are submitting. Choose between 'Initial' or other changes, and provide the legal agency name and the trading name (if applicable). Ensure your email address and phone number are correctly entered.
4. Complete the business address section. Input the physical location details such as street number, city, state, and ZIP code. If your mailing address differs, provide that information as well.
5. In the ownership section, specify the type of business organization and list the names, titles, and addresses of owners with a 2% or more ownership stake. Include their percentage owned.
6. Respond to the background section questions regarding any previous license issues, compliance with civil rights regulations, and any criminal convictions related to healthcare services. Provide explanations where applicable.
7. If your agency has employees, complete the workers' compensation section by providing the policy number, effective dates, and insurance company details. Attach a copy of your workers' compensation insurance policy if indicated.
8. Proceed through specialized sections if applicable, such as for freestanding ambulatory surgery centers, birthing centers, or kidney dialysis facilities, detailing services, accreditation, and director information.
9. Read and complete the affidavit section at the end of the form. This section requires your signature, title, and date, affirming the truthfulness of the information provided.
10. Finally, review the entire form for completeness and accuracy. Save your changes, then download, print, or share the form as needed.

Get started on your application today by completing the MD DHMH AC.APP.1.0 form online.