Delaware Health and Social Services
Division of Public Health
 
APPLICATION FOR FREE STANDING SURGICAL 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 
 

Facility Type 
  
  
________ Single Specialty      Identify:___________________________ 
              					 PLEASE PRINT 
  
________ Multi-Specialty (list) 
 
Please complete the following section using the square footage requirements of the 
Design and Construction Guidelines in use at the time of initial licensure as well 
as the “American College of Surgeons Classes of Surgical Facilities”.  If there is 
ambiguity or conflict, prior written clarification from this office is required. 
 
NUMBER OF CLASS A OPERATING ROOMS/ PROCEDURE ROOMS 	________
  
TOTAL NUMBER OF PREP/RECOVERY BEDS (DUAL USE) 		________
  
NUMBER OF CLASS B OPERATING ROOMS 			________

TOTAL NUMBER OF OF PREP BEDS 				________
  
NUMBER OF CLASS C OPERATING ROOMS 			________
  
TOTAL NUMBER RECOVERY BEDS 				________
  
TOTAL NUMBER OF OPERATING ROOMS 			________	

  
ACCREDITED? 
  
________ YES 		BY WHOM: _______________________________________

Include effective expiration  	 _______________________________________			 
dates per agency 				 
  				 _______________________________________
________ 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) 

4. 	ACCREDITING AGENCY(IES) REPORT(S)

5. 	FIRE SAFETY REPORT 

6. 	FOR RE-LICENSURE: PHONE DIRECTORY (INCLUDE EMAIL ADDRESSES IF AVAILABLE TO 
	OHFLC FOR USE) 
 
7. 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: $250.00
  
ANNUAL LICENSURE FEE:  $50.00 
 
PLEASE COMPLETE AND RETURN APPLICATION WITH LICENSURE FEE TO 
 
OFFICE  OF HEALTH FACILITIES LICENSING & CERTIFICATION 
 
2055 LIMESTONE ROAD 
 
SUITE 200 
 
WILMINGTON DE  19808 
 
03/06  

Doc. No. # 35-05-20/08/02/50