*This application consists of 3 pages which must be completed 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name in the designated field at the top of the first page. Ensure that all information is accurate and complete.
3. In the section describing your facility, check all applicable boxes that best represent your services. This helps clarify the type of care you provide.
4. For each service type listed, input the projected number of visits and revenues where applicable. If a service does not apply, indicate 'N/A'.
5. Complete the licensure and accreditation section by checking 'Yes', 'No', or 'N/A' for each question. Provide details for any accreditations with their most recent survey dates.
6. Fill out operational hours and ensure a medical professional's presence during those hours is noted accurately.
7. Review all policies and procedures listed, marking them as approved or not, and provide explanations for any 'No' responses in the comments section.
8. Finally, sign and date the application at the bottom of the last page to confirm accuracy before submission.

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