| How to Apply/Renew/Amend a Health Care Facility(Imaging/Radiation Therapy Centers) License by Mail
Use the following chart as a guideline when applying, renewing or amending a license.
|
Initial
Application |
Renewal
Application |
Amendment
Application |
| Fill out necessary forms |
HEA5134 |
Renewal Application Mailed to facility |
HEA5135 |
| Application Fee |
$300 |
$300 |
$150 (when applicable) |
| Fire Inspection Report (within last 12 months) |
X |
X |
(address change or building renovation only) |
| Use and Occupancy Report |
X |
|
(address change or building renovation only) |
| Notarized Affidavit (required when someone other than an owner signs application) |
X |
X |
X |
| Renewal Notice mailed to you. |
|
X |
|
Forms are in PDF format. The free Adobe Acrobat Viewer is required to view them.
Mail to:
Ohio Department of Health
Health Care Facility Program
Attn: Revenue Processing - 3600
P.O. Box 15278
Columbus, OH 43215
Telephone: (614) 644-2727
Last Updated: 7/31/08
Last Reviewed: 9/29/11
Health Care Facility (Imaging/Radiation Therapy Centers) / Radiation Protection
|
