Get Outpatientrenaldialysisfacilityapp.doc - Public Health Oregon

This guide will assist users in completing the Outpatient Renal Dialysis Facility Application form accurately and efficiently. By following the detailed steps outlined below, users will ensure that all required information is provided for a successful application.

Follow the steps to complete the application form online.

1. Press the ‘Get Form’ button to access the application form and open it in your chosen editor.
2. Select the type of action you are applying for by checking the appropriate box, such as 'New Facility', 'License Renewal', or 'Ownership Change'. If applicable, provide the effective date of the change.
3. If your facility has an existing license, enter the license number and provider number, if applicable. Indicate whether the facility is accredited and, if so, name the accrediting agency.
4. Provide detailed facility information, including whether your facility operates as a profit or non-profit entity. Include the facility's legal name, 'Doing Business As' name if applicable, physical address, phone number, and fax number.
5. If the mailing address differs from the physical address, fill in the mailing address. Include the county in which the facility is located, the fiscal year ending date, and the contact information for the administrator and facility manager.
6. List number of dialysis stations and days and hours of operation. Make sure to provide accurate and complete information.
7. Provide owner information, including ownership category and type, and name, address, and contact details of each owner. If there are multiple owners, additional pages may be necessary.
8. Complete the declaration by signing and dating the form to affirm that the information provided is accurate, and include any necessary payment information as per the fee schedule listed.
9. Once all fields are completed, save changes to the form. You may then choose to download, print, or share the completed application as needed.

Start filling out your application online today to ensure timely processing.