State Regulation Waiver Application: Licensed Hospitals for Alternate Care Site (Capacity Increase) Due to COVID-19 Inpatient Needs Survey

1.Applicant Facility Information(Required.)

Applicant Facility Name

Applicant Current Facility Type

Applicant Current License #

Applicant Address (# and Street)

Applicant Address (City, State, Zip)

Applicant Facility Administrator Name

Applicant Facility Administrator Telephone Number

Applicant Facility Administrator Email Address

Number of Beds at Alternate Care Facility requested

2.Alternate Care Site Information(Required.)

Alternate Care Site Name

Alternate Care Site Facility Type

Alternate Care Site License #

Alternate Care Site Address (# and Street)

Alternate Care Site Address (City, State, Zip)

Alternate Care Site Administrator Name

Alternate Care Site Administrator Telephone Number

Alternate Care Site Administrator Email Address

3.Will the Alternate Care Site continue to operate under its current license in some capacity?

**NOTE: If the Alternate Care Site is a licensed Ambulatory Surgical Center or a Community Clinic with Emergency Center, it must cease operating as such during the time that the Applicant Facility provides hospital services.(Required.)

Yes

Current Progress,

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State Regulation Waiver Application: Licensed Hospitals for Alternate Care Site (Capacity Increase) Due to COVID-19 Inpatient Needs

4.