PDF njaasc-facility-application copy 2026

1. Click ‘Get Form’ to open the PDF njaasc-facility-application copy in our editor.
2. Begin by filling out the 'Primary Contact' section. Enter your company name, website, specialty, phone number, and address details including city and state.
3. In the 'Additional Employee Emails' section, provide names and email addresses of any additional employees who should be contacted regarding the application.
4. Complete the 'Additional Information' section by indicating whether your facility is licensed by the NJ Department of Health and providing ownership percentages.
5. Fill in the 'Medical Director/Facility Owner' section with the name and contact information of the responsible individual.
6. Select your preferred payment type under 'Payment Type', and if paying by credit card, complete the 'Credit Card Information' fields accurately.
7. Indicate who referred you in the designated field and answer whether your facility is Medicare-certified.
8. Finally, sign and date the application at the bottom to authorize verification of provided information.

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