Delaware Health and Social Services
Division of Public Health

 
APPLICATION FOR FREE STANDING EMERGENCY CENTER LICENSE 
 
FACILITY NAME 	________________________________________________________________________
						Print 
 
FACILITY ADDRESS _______________________________________________________________________
 						ADDRESS 1 
 
 		________________________________________________________________________
 						ADDRESS 2 
 

		______________________________________	_______________	________________
  				CITY			     STATE	    ZIP CODE 
 

ADMINISTRATOR/CEO ______________________________________________________________________ 
  						Print 
 

MEDICAL DIRECTOR  ______________________________________________________________________
		    				Print 

 		M.D. License #:__________________      Exp. Date:______________
 
DIRECTOR OF NURSING  ___________________________________________________________________
		    				Print 

 		R.N. License #:__________________      Exp. Date:______________


FACILITY CONTACT  ______________________________________________________________________
					   Print Name and Title

PHONE NUMBERS	_______________________   ______________________   _____________________ 
 		 FACILITY PHONE NUMBER     CONTACT PHONE NUMBER         CONTACT FAX 
  

NUMBER OF EMERGENCY BAYS  ______
  
  
ACCREDITED?  		______ YES  BY WHOM:	________________________________________________ 
Include effective 
expiration dates per agency			________________________________________________ 
  
			______ NO 
 
 
ALL PHYSICIANS ARE CERTIFIED IN ACLS OR EMERGENCY MEDICINE  	_____ YES  ______ NO 
 
AT LEAST ONE NURSE ON EACH SHIFT IS CERTIFIED IN ACLS 		_____ YES  ______ NO 
 

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. 	ACCREDITING AGENCY(IES) CERTIFICATE(S) AND REPORT(S) 
 
4. 	FIRE SAFETY REPORT 
 
5. 	OTHER: 	__________________________________________________________________            

		__________________________________________________________________
 

****PLEASE ATTACH A TABLE SHOWING TWENTY-FOUR (24) HOUR STAFFING**** 

 
NAME OF PERSON COMPLETING THIS FORM:_______________________________________________ 
 
                                                                                                                                                                    PRINT 
 
 
 
SIGNATURE:____________________________     TITLE:_________________________________ 

 
DATE:___________________________ 

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

INITIAL APPLICATION FEE:  $250.00
  
ANNUAL LICENSURE FEE:  $150.00 
 
 
PLEASE COMPLETE AND RETURN APPLICATION WITH LICENSURE FEE TO 
 
OFFICE  OF HEALTH FACILITIES LICENSING & CERTIFICATION 
 
2055 LIMESTONE ROAD 
 
SUITE 200 
 
WILMINGTON DE  19808 
 
Doc. No. # 35-05-20/08/02/49 
02/05