Applications and Forms for Health Facilities

DHSS State of Alaska

Health and Social Services > Health Care Services > Applications and Forms for Health Facilities

Applications & Forms for Health Facilities

Criminal Background Variance Request Application form
- Application for Variance Request form -PDF
  
  Facilities who wish to request a variance for an employee who has a barrier crime must fill out the above form and submit it and all additional required documentation to Shelby Larsen. Only licensed entities may submit request for a variance. You can call Shelby at 907-334-2481 for more information.
New Facilities and Federal Certification Information
License Applications
- Ambulatory Surgical Centers (ASC)
  ASC Application Initial - PDF
  ASC Application Renewal - PDF
- Free-Standing Birth Centers
  Birth Center Application
- Frontier Extended Stay Clinics (FESC)
  FESC Application
- Home Health Agencies (HHA)
  HHA Application
- Hospice Agencies
  Hospice Licensure Application
- Hospitals (This application applies to all hospitals including General Acute Care, Rural Primary Care, Critical Access, Long Term Acute Care, and Specialized Hospitals.)
  Hospital Application
- Nursing Homes (LTC) (Initial licensure applications for nursing homes must include both the following forms. Renewal only requires the LTC Application.)
  Initial LTC
  LTC Application
Request for General Variance
Request for General Variance Form
Complaint Form (Individuals may use this form to provide information relative to a complaint regarding any licensed facility.
Complaint Form Fillable