Ohio licensure 2025

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4.8 out of 5

154 votes

The document is an application form for licensure of a Class Two Residential Facility by the Ohio Department of Mental Health and Addiction Services. It outlines the requirements for providing accommodations, supervision, and personal care services to individuals with mental illness or adults receiving state supplement payments. The application includes sections for facility information, ownership details, emergency contacts, resident rights advocate, requested license capacity, and various compliance checks. A fee of $75 is required along with supporting documentation.

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Click ‘Get Form’ to open the Ohio Licensure application in the editor.
Begin by selecting the Application Type: Initial or Renewal. Indicate the population you will serve, either Children/Adolescents or Adults.
Fill in the Residential Facility Information, including Facility Name, Phone Number, Street Address, City, Zip Code, and County.
Provide your Mailing Address for official correspondence. Choose whether to mail to the Facility Address or another specified address.
Complete the Emergency Contact Information section with a number different from the facility phone number and provide details for both Owner/Operator and Manager.
Select your Ownership/Organization Structure and fill in relevant Owner/Operator Information. Ensure all contact details are accurate.
Attach any required supporting documentation as specified in the instructions section of the form before submitting it through our platform.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (154 Votes)

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