DHCQ-licensed facilities may use the following applications, forms, and portals.
Applications
- Blueprint Review
- CNA Applications
- Licensure Initial Application – Part I
- Licensure Renewal
Forms/Portals
- State Civil Money Penalty Request Form
- CMS Federal Civil Money Penalty Reinvestment
- Direct Care Worker Disclosure
- Durable Personal Power of Attorney
- Facility Change of Information
- Incident Response Portal
- Interagency Patient Transfer
- Interested Provider Receipt of Acknowledgement
- Licensing and Certification Statement of Intent
- Office-Based Surgery Facility Registration
- RN/LPH Attestation
- Uniform Assessment Instrument
