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.
- Application for Variance Request form -PDF
- 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
- Ambulatory Surgical Centers (ASC)
- 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
- For more information, please contact us.
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