Delaware APPENDIX 1 — FORM of FACILITY-BASED PROVIDER DISCLOSURE (Word doc) is the official document that must be completed and submitted to the Delaware Department of Insurance for those providers operating a facility-based business in the state. This form includes information such as the facility's name and address, the contact information for the provider, and the type of services provided. It also outlines the provider's professional qualifications, insurance coverage, and any other relevant information. There are two types of Delaware APPENDIX 1 — FORM of FACILITY-BASED PROVIDER DISCLOSURE (Word doc): the Facility-Based Provider Disclosure and the Surgeon's Provider Disclosure. The Facility-Based Provider Disclosure must be completed for any provider operating a facility-based business in Delaware, while the Surgeon's Provider Disclosure must be completed for any surgeon providing services in the state. Both forms require the provider to provide information such as their license and certification information, insurance coverage information, and any other relevant information.