Topics
  A-Z		 Data &
 Statistics		 Forms &
Publications		 News &
Advisories		 Licensing &
Certification		 Rules &
Regulations		 Public Health
Directory
Print this Article   Bookmark and Share
Forms, Applications and License Information
HCRQI Forms, Applications & License Information

The following forms are available to download. Please note, licensure lists are updated quarterly. The lists on this page were posted on January 14, 2013. If you need any of these documents in large print, please contact Health Care Regulation and Quality Improvement:

Phone: 971-673-0540
Fax: 971-673-0556
TTY: 971-673-0372

All files are in Adobe format. Download the free Adobe Reader.

Applications, Forms & License Information


AMBULATORY SURGERY CENTERS
     - ASC License Application Form License Application Form
     - ASC Initial Licensing Information Licensing Information
     - ASC Initial Certification Info & CMS Checklist Certification Information
CMS Certification Checklist
     - ASC Determination Form Determination Form
     - ASC Rule Fact Sheet Rule change information
 

ASC Licensed Facility List*
Licensed ASC Facilities

BIRTHING CENTERS
     - BC License Application Form License Application Form
     - BC Initial Licensing Information License information
 

Birthing Center Licensed Facility List*
Licensed BC Facilities

CAREGIVER REGISTRIES
     - CGR License Application Form License Application Form
     - CGR Initial Licensure Information Initial Licensure Info
     - CGR Determination Form Determination Form
 

Caregiver Registries Licensed Agency List*
Licensed CGR Agencies

OUTPATIENT RENAL DIALYSIS FACILITY (ESRD)
    - ORDF License Application Form License Application Form
    - ORDF Initial Licensure Information Licensure Information
    - ORDF Initial Certification Info & CMS Checklist Certification Information
CMS Certification Checklist
    - ORDF Change of Ownership Information CHOW Information
    - ORDF Rule Fact Sheet Rule change information
 

Outpatient Renal Dialysis Licensed Facility List*
Licensed ORDF Facilities 

HOME HEALTH AGENCY
    - HHA License Application Form License Application Form
    - HHA Initial Licensure Information Licensure Information
    - HHA Initial Certification Info & CMS Checklist Certification Information
CMS Certification Checklist
    - HHA Change of Ownership Information CHOW Information
    - HHA Rule Fact Sheet Rule change information
    - HHA Crime list for background check Background check crimes
    - HHA Owner/Admin Background Check Request Background check request
 

Home Health Agency Licensed Facility List*
Licensed HHA Facilities

HOSPICE 
    - Hospice License Application Form License Application Form
    - Hospice Initial Licensure Information Licensure Information
    - Hospice Initial Certification Info & CMS Checklist Certification Information
CMS Certification Checklist
    - Hospice Change of Ownership Information CHOW Information
    - Hospice Licensure FAQ Frequently Asked Questions
 

Hospice Licensed Facility List*
Licensed Hospice Facilities

HOSPITAL**
    - Hospital License Application Form License Application Form
    - Hospital Satellite Information/Addition Satellite Addition Information
    - Hospital Rule Fact Sheet Rule change information
    - Hospital Complaint Invoice Information Sheet Complaint invoice information
    - Hospital Trauma Designation Trauma Designation
 

Hospital Licensed Facility List*

Hospital Licensed Satellite List
Licensed Hospital Facilities

Licensed Satellite List

IN-HOME CARE AGENCY
    - IHC License Application Form License Application Form
    - IHC Initial License FAQ                         Frequently asked questions
    - IHC Determination Form Determination form
    - IHC Survey Preparation Checklist Checklist
    - IHC New Rules Information Information on New Rules
    - IHC Memo aQuire Class approval Information on Training
    - IHC Self Direct Evaluation Form Self Direct Evaluation Form
    - IHC Background Check Crimes List Background Crimes List
    - IHC Owner/Admin Background Check Request Background Check Request
 

In Home Care Licensed Agency List*
Licensed IHC Agencies

SPECIAL IN PATIENT CARE FACILITY
    - SICF License Application Form License Application Form


SICF Licensed Facility List*
Licensed SIC Facilities

ORGAN PROCUREMENT
    - OP License Application Form License Application Form

RURAL HEALTH CLINIC
    - RHC Initial Certification Info & CMS Checklist Certification Information
CMS Certification Checklist
    - RHC Change of Ownership CHOW Information
 

List of Oregon RHCs**
Certified RHC List
   
COMPLAINT INTAKE FORM & Referral List
    - Complaint Intake Form Complaint Intake Form
    - Complaint Referral List Complaint Referral List

DISCLOSURE OF RECORDS REQUEST
    - Disclosure of Records Request Records Request Form

ALL LICENSURE FEE SCHEDULE
    - Fee Schedule Licensure Fee Schedule

WAIVER REQUEST
    - Waiver Request  Information & Form Waiver Request Info & Form

HEMODIALYSIS TECHNICIAN
    - Hemo Tech Application Certification Application
    - Hemo Tech Fee Schedule & FAQ Fee Schedule & FAQ


Licensed Hemodialysis Technicians**


Licensed Hemo Techs


*Please note all license lists are updated quarterly. If you have any questions about the license lists, email your inquiry to mailbox.hclc@state.or.us.

**HOSPITALS - New fees for hospitals and special inpatient care facilities went into effect on January 1, 2011. The revised application form was posted on December 31, 2010. Hospitals submitting their applications after December 31, 2010 will need to pay the new fee. Fees are identified in ORS 441.020.

**Note for Hospitals Providing Home Health Services:

In accordance with ORS 433.025, a hospital licensed under ORS 441.015 may provide home health services so long as the services provided meet the requirements of ORS 443.005 to 443.105 and the hospital pays the home health licensing fees. There will no longer be any fee exemptions for hospitals providing home health services.