Ambulatory Surgery Center Licensing Application Form

Ambulatory Surgery Center Licensing Application Form
Complete this application to request licensing for an ambulatory surgery center. Please provide accurate and complete facility and contact details for processing.
Facility Legal Name
DBA/Trade Name (if any)
Facility Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Contact Information
First NameLast Name
Primary Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Contact Email Address
example@example.com
Facility License/Application Category
Facility Details
Rows Number of Operating Rooms Number of Procedure Rooms Planned Opening Date
Enter details
Ownership Type
Other
Accreditation Status
Medical Director Name and Facility Operations
Emergency Transfer Agreement Status
Should be Empty:

Rows	Number of Operating Rooms	Number of Procedure Rooms	Planned Opening Date
Enter details

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