Delaware Health and SOcial Services
Division of Public Health
 
 
APPLICATION FOR HOSPITAL LICENSE 

FACILITY NAME 	________________________________________________________________________
						Print 
 
FACILITY ADDRESS _______________________________________________________________________
 						ADDRESS 1 
 
 		________________________________________________________________________
 						ADDRESS 2 
 

		______________________________________	_______________	________________
  				CITY			     STATE	    ZIP CODE 
 

ADMINISTRATOR/CEO ______________________________________________________________________ 
  						Print 
 

CONTACT   	  ______________________________________________________________________
		    			        Print 


		  ______________________________________________________________________
					     Position and Title

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

 
 
FACILITY TYPE 			______  ACUTE CARE		______ LONG TERM ACUTE CARE 
PLEASE CHECK ALL THAT APPLY 
  				______  PSYCHIATRIC CARE	______ CHILDREN 
 
 				______  REHABILITATION: ________________________________

	       
TYPE OF CONTROL 		______  NON-PROFIT		______ FOR-PROFIT 
 
 				______  STATE GOVERNMENT	______ OTHER:______________ 
 
 
  
TOTAL NUMBER OF LICENSED BEDS 	______		BASSINET CAPACITY ______
  
TOTAL NUMBER OF OPERATING BEDS  ______
  
TOTAL ANNUAL PATIENT DAYS 	______		TOTAL ANNUAL OUTPATIENT VISITS* ______
  
 
*A visit to each organized outpatient care program by a person who is not an inpatient 
(does not include the number of diagnostic &/or therapeutic treatments received). 
  

ACCREDITED? 			______  YES    BY WHOM:	___________________________________
Include effective expiration 				
dates per agency 		______  NO		___________________________________
  
							___________________________________ 
 

AFFILIATED WITH A MEDICAL SCHOOL 
 
 						 IDENTIFY 
 
 
______	MAJOR		___________________________________________________________________ 
  
______  LIMITED		___________________________________________________________________ 
  
______  GRADUATE 	___________________________________________________________________
  
______  NO AFFILIATION 	___________________________________________________________________
  
  
RESIDENT PROGRAMS APPROVED BY (CHECK ALL THAT APPLY) 
 
	______ AMA	______ ADA 
	
	______ AOA	______ OTHER:  _______________________________     
 
 	______ NO PROGRAM 
  

AUTHORIZED OFFICIAL 	


__________________________________________________  _______________________________________
  		    PRINT NAME 					 PRINT TITLE 
 
 

__________________________________________________________  _______________________________  
			 SIGNATURE					DATE 
 
 
 
PLEASE ATTACH THE MOST CURRENT COPY OF THE FOLLOWING: 
 
1. 	HOSPITAL DIRECTORY THAT (AT A MINIMUM) IDENTIFIES THE SERVICE DEPARTMENTS AVAILABLE, 
	THE DEPARTMENT MANAGER AND PHONE NUMBER. 
 
2. 	A LIST (INCL. NAME, ADDRESS, TYPE OF SERVICE) OF ALL OFF-SITE/OFF-CAMPUS SERVICES 
	THAT ARE INLUDED IN YOUR STATE LICENSE AND/OR FEDERAL CERTIFICATION AND/OR 
	ACCREDITATION. 

3. 	FIRE SAFETY REPORT. 

4. 	ACCREDITING AGENCY(IES) CERTIFICATE(S). 

5. 	ACCREDITING AGENCY(IES) REPORT(S). 

6. 	OTHER:	________________________________________________________            

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


INITIAL APPLICATION FEES:		  ANNUAL LICENSURE FEES:	 	

	100 BEDS OR LESS	$250.00 	100 BEDS OR LESS 	$150.00
  
 	OVER 100 BEDS 		$375.00 	OVER 100 BEDS 		$250.00
  
  
 
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. # 35-05-20/08/02/55
12/07