Maryland form ac: Fill out & sign online

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'General Information' section. Select the type of license you are applying for and indicate whether this is an initial application or a change.
Provide your legal agency name, trading name (DBA), email address, phone number, and both business and mailing addresses. Ensure all contact information is accurate.
In the 'Ownership' section, specify your business organization type and list the names, titles, and addresses of owners with 2% or more ownership.
Complete the 'Background' section by answering questions regarding any past license issues or criminal offenses related to healthcare.
If applicable, provide details about workers’ compensation insurance in the designated section.
Continue through each specific section relevant to your facility type (e.g., Ambulatory Surgery Center, Home Health Agency) ensuring all required fields are filled accurately.
Finally, review your entries for accuracy before signing the affidavit at the end of the form.

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