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Forms, Applications and License Information

The following forms are available to download. Please note, licensure lists are updated quarterly: January, April, July and October of each year. The lists on this page were posted on July 31, 2014. 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
HHA-IHC Attestation Form​ Attestation Form
  

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 Administrator Application Form​ Administrator Application Form​
IHC Initial Agency Packet [FAQ] Initial Agency Packet
​IHC Change of License Classification Change of License Classification
IHC Determination Form Determination form
IHC Relicensure Survey Tool Relicensure Survey Tool
IHC New Rules Information Information on New Rules
IHC Change of Ownership Instructions  Change of Ownership Instructions
IHC Branch Office Instructions​ Branch Office Instructions
IHC Self Direct Evaluation Form Self Direct Evaluation Form
IHC aQuire Class approval Memo Information on Training
IHC Orientation/Training/Competency Evaluation Memo Orientation/Training/Competency Evaluation Memo
IHC Criminal History Check Memo (2-2014) Criminal History Check Memo
IHC Administrator Requirements Memo Administrator Requirements Memo​
IHC Policy and Procedure Memo Policy and Procedure Memo
IHC Owner/Admin Background Check Request Background Check Request
IHC Background Check Crimes List​ Background Crimes List
 

In Home Care Licensed Agency List*


Licensed IHC Agencies

NONTRANSPLANT ANATOMICAL RESEARCH RECOVERY ORGANIZATION (NARRO)
​NARRO License Application Form
NARRO License Application Form
​NARRO OAR Fact Sheet NARRO OAR Fact Sheet
​NARRO Licensing Survey Tool NARRO Licensing Survey Tool


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

List of Registered Organ Procurement Organizations*

Registered OP Organizations


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

Hemodialysis Tech Application Certification Application
Hemodialysis 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.