Fillable PUBLIC HEALTH LICENSING SERVICES Residential Facilities Licensing 150 (Arizona Department of Health Services)

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PUBLIC HEALTH LICENSING SERVICES Residential Facilities Licensing 150 (Arizona Department of Health Services)

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PUBLIC HEALTH LICENSING SERVICES
Residential Facilities Licensing
150 N. 18th Avenue
Phoenix, AZ 85007
APPLICATION AND LICENSE FEE REMITTANCE FORM
PLEASE RETURN THIS FORM WITH PAYMENT TO ABOVE ADDRESS
FACILITY ID #: (Office use ONLY)
LICENSE #: (Renewals ONLY) _____________________
FACILITY NAME:
STREET ADDRESS:
CITY:
STATE:
ZIP:
ADULT DAY HEALTH CARE FACILITY, ASSISTED LIVING HOME, OR ASSISTED LIVING CENTER
FEES AMOUNT DUE
Application Fee
(due when application is submitted) $50
Licensed Capacity (due after initial inspection)
Licensed Capacity:
License Fee: # of Beds x $70 each: Total License Fee + Number of Beds Fee:
No licensed capacity
$280 N/A
$
280
1 to 59 beds
$280
______ x $70 = ____________
$__________
60 to 99 beds
$560
______ x $70 = ____________
$__________
100 to 149 beds
$840
______ x $70 = ____________
$__________
150 or more beds
$1400
______ x $70 = ____________
$__________
TOTAL AMOUNT DUE
$__________
BEHAVIORAL HEALTH RESIDENTIAL FACILITY,
ADULT BEHAVIORAL HEALTH THERAPEUTIC HOME,
ADULT BEHAVIORAL HEALTH RESPITE HOME, OR
CHILDREN’S BEHAVIORAL HEALTH RESPITE HOME
FEES AMOUNT DUE
Application Fee (due when application is submitted) $50
Licensed Capacity (due after initial inspection)
Licensed Capacity: License Fee: # of Beds x $94 each: Total License Fee + Number of Beds Fee:
No licensed capacity $375
N/A
$375
1 to 59 beds $375
______ x $94 = ____________
$__________
60 to 99 beds $750
______ x $94 = ____________
$__________
100 to 149 beds $1125
______ x $94 = ____________
$__________
150 or more beds $1875
______ x $94 = ____________
$__________
TOTAL AMOUNT DUE
$__________
Payment should be
cashiers’ check, money order or business check made payable to: AZ DEPT OF HEALTH SERVICES
Cash and
personal checks are not accepted.
ALL FEES ARE NON-REFUNDABLE pursuant to A.R.S. 36-405(B)(6), 36-882(f) and 36-897.01(c), except as provided in
A.R.S. 41-1077. NOTE: Fees do not apply to a health care institution operated by a State agency pursuant to federal law such
as the Veterans’ Home, Arizona State Hospital or adult foster care settings. Authority: A.R.S. 36-405
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PUBLIC HEALTH LICENSING SERVICES Residential Facilities Licensing 150 (Arizona Department of Health Services)

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Completed 21 March 2022

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