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Forms, Applications and License Information

Facilities Planning and Safety has moved to Portland!

Read the notice for details (pdf)​


Facilities Planning and Safety Workload Update: July 24, 2015

Dear Stakeholders,

Facilities Planning and Safety is pleased to announce that two (2) of our vacant Plans Examiner positions and one (1) Administrative Support position have now been filled. We are also pleased to announce that our additional recruitment requests have been authorized, and we expect to fill our two (2) remaining Plans Examiner positions soon.

Thank you for your continued patience and understanding while we work through existing resource constraints. We recognize and appreciate the degree to which our stakeholders have shared in the challenges that we have faced during the past few months.

In the coming weeks, we will update our website to include real-time project queue information. This will include the project record numbers (PR#s) our team is currently reviewing, updated on a weekly basis. Thank you again for your support. We look forward to working with you in the future and to our continued partnership to improve the safety of health care facilities across Oregon.


Please Note

Licensure lists are updated quarterly (January, April, July and October) of each year. The lists on this page were posted on April 29, 2015. If you have any questions about the lists, e-mail your inquiry to mailbox.hclc@state.or.us

Forms, Applications and License Information

If you need documents in large print, please contact us.


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 


HEMODIALYSIS TECHNICIAN

Hemodialysis Tech Application Certification Application
Hemodialysis Tech Fee Schedule & FAQ Fee Schedule & FAQ


Certified Hemodialysis Technicians


Certified Hemo Technicians

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​
New Satellite Location Process Instructions New Satellite Instructions​​
Hospital Rule Fact Sheet Rule change information
Hospital Complaint Invoice Information Sheet Complaint invoice information
Hospital Trauma Designation Trauma Designation
​Hospital Change of Ownership Instructions ​Change of Ownership Instructions
​Hospital Instructions for Building Construction for Addition of New Services ​Construction for Addition of New Services Instructions
​Hospital Instructions for Building Construction for Existing Services Construction for Existing Services Instructions​
 

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

NARRO Licensed Facility List
 

NARRO Licensed Facilities​


ORGAN PROCUREMENT ORGANIZATIONS
TISSUE BANKS / EYE BANKS

OP Registration Form Registration Form
 

List of Registered Organ Procurement Organizations
 


Registered OP Organizations


RURAL HEALTH CLINIC

RHC Initial Certification Information and
CMS Checklist
Certification Information​
CMS Certification Checklist
RHC Change of Ownership CHOW Information
 

List of Oregon RHCs
 


Certified RHC List

 
SPECIAL IN-PATIENT CARE FACILITY

SICF License Application Form License Application Form​


SICF Licensed Facility List
 


Licensed SIC Facilities

   
COMPLAINTS

Complaint Intake Form Complaint Intake Form
Complaint Referral List Complaint Referral List


PUBLIC RECORDS REQUESTS

Request for Disclosure of Public Records Public Records Request Form


ALL LICENSURE FEE SCHEDULE

Fee Schedule Licensure Fee Schedule


WAIVER REQUEST

Waiver Request Form & Instructions
Waiver Request Form & Instructions
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