Get Birthingcentersapp.doc - Public Health Oregon

This guide provides step-by-step instructions for completing the BirthingCentersAPP.doc, a vital document required for licensing changes with Public Health Oregon. Whether you're making an ownership change or renewing a license, these comprehensive instructions will help ensure that you complete the form accurately.

Follow the steps to fill out the BirthingCentersAPP.doc effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by selecting the type of action you are taking. Indicate whether it is an ownership change, license renewal, or name/address change. If you select 'Other,' please specify your reason.
3. Fill in the effective date of change, if applicable, and ensure that any action requiring a fee payment is noted.
4. Complete the facility information section by entering the facility's legal name, DBA (Doing Business As) name if applicable, and the physical address, including city, state, and ZIP code. Provide the facility's phone and fax number, as well as the mailing address if it differs from the physical address.
5. In the county field, specify the county where your facility is located. Include the facility's email and the fiscal year ending date in MM/DD format.
6. Enter the name and phone number of the administrator, followed by their email address. Include contact information for an emergency contact person.
7. Indicate the days and hours of routine operation for the facility.
8. Provide detailed owner information, including the type of ownership (individual, corporation, partnership, non-profit, etc.) and if it is a partnership or corporation, list each person with 5% or more interest on an additional page.
9. Include the tax ID number and the name, address, phone number, and fax of the owner(s).
10. Read the declaration statement carefully, confirming the accuracy of the information provided. Ensure the administrator signs the form, prints their name and title, and includes the date in MM/DD/YYYY format.
11. Complete any required fee payment, ensuring that checks are made payable to the Oregon Health Authority and sent to the designated mailing address.
12. Once all sections are completed, save your changes, and proceed to download, print, or share the form as needed.

We encourage you to complete the BirthingCentersAPP.doc online to streamline your licensing process.