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- Click ‘Get Form’ to open the PDF njaasc-facility-application copy in our editor.
- Begin by filling out the 'Primary Contact' section. Enter your company name, website, specialty, phone number, and address details including city and state.
- In the 'Additional Employee Emails' section, provide names and email addresses of any additional employees who should be contacted regarding the application.
- Complete the 'Additional Information' section by indicating whether your facility is licensed by the NJ Department of Health and providing ownership percentages.
- Fill in the 'Medical Director/Facility Owner' section with the name and contact information of the responsible individual.
- Select your preferred payment type under 'Payment Type', and if paying by credit card, complete the 'Credit Card Information' fields accurately.
- Indicate who referred you in the designated field and answer whether your facility is Medicare-certified.
- Finally, sign and date the application at the bottom to authorize verification of provided information.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2021 | 4.8 Satisfied (35 Votes) |
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