APPLICATION FOR FREE STANDING BIRTHING CENTER LICENSE 

FACILITY NAME ______________________________________________________________________
					     Print 
 
FACILITY ADDRESS ___________________________________________________________________
					   ADDRESS 1 

 		 ___________________________________________________________________
					   ADDRESS 2 
 
 		 ______________________________  __________________  _______________
  			     CITY 		       STATE	         ZIP CODE 
 

ADMINISTRATOR/CEO __________________________________________________________________ 
			 		     Print 

FACILITY CONTACT ___________________________________________________________________
				     Print Name and Title 

PHONE NUMBERS  ______________________  ______________________  _____________________ 
  	       FACILITY PHONE NUMBER   CONTACT PHONE NUMBER    CONTACT FAX   
  
 
NUMBER OF BIRTHING ROOMS __________
  
NUMBER OF PHYSICIANS WITH PRIVILEGES __________
  
NUMBER OF CERTIFIED NURSE MID-WIVES WITH PRIVILEGES __________

ALL PHYSICIANS HAVE ADMITTING PRIVELEGES TO AREA HOSPITAL(S)  _____ YES  _____ NO 
 
ALL CERTIFIED NURSE MID-WIVES HAVE A BACK-UP AGREEMENT  _____ YES  _____ NO 
WITH A PHYSICIAN 
  
ACCREDITED?  _____ YES	_____ NO 
 
IF YES, NAME OF ACCREDITING ORGANIZATION AND ACCREDITATION EXPIRATION DATE: 
 
____________________________________________________________________________ 
                                   Print 
 
PLEASE ATTACH THE MOST CURRENT COPY OF THE FOLLOWING: 
 
1.  	A LIST SHOWING THE NAMES AND ADDRESSES OF EACH OFFICER, DIRECTOR, AND OWNER HAVING 
	TEN (10) PERCENT OR MORE INTEREST IN THE FACILITY. 
 
2.  	A LIST SHOWING THE NAMES AND ADDRESSES OF THE GOVERNING BODY, IF DIFFERENT FROM 
	THE PRECEDING GROUP. 
 
3. 	Fire Safety Report 
 
4.  	OTHER 
 
 
NAME OF PERSON COMPLETING THIS FORM:_______________________________________________ 
                                                        PRINT 
 
 
 
SIGNATURE:_____________________________    TITLE:________________________________ 
 
DATE:_______________________ 

 
CHECKS SHOULD BE MADE PAYABLE TO:  DELAWARE DIVISION OF PUBLIC HEALTH 

 
INITIAL APPLICATION FEE:  $150.00
  
ANNUAL LICENSURE FEE: $75.00
 
PLEASE COMPLETE AND RETURN APPLICATION WITH LICENSURE FEE TO 
 
OFFICE  OF HEALTH FACILITIES LICENSING & CERTIFICATION 
 
2055 LIMESTONE ROAD 
 
SUITE 200 
 
WILMINGTON DE  19808 
 
10/06  
Doc. No. # 35-05-20/08/02/48