State Regulation Waiver Application: Ambulatory Surgical Center for Alternate Care Site Due to COVID-19 Inpatient Needs

1.

PLEASE NOTE: This application should only be used by licensed Ambulatory Surgical Centers that intend to operate independently as Alternate Care Sites and is only for waivers of Colorado state regulations.

The regulations governing the process of granting or denying applications for waiver of regulations pertaining to health facilities in Colorado can be found in Chapter 2, Part 5 of the Department’s Standards for Hospital and Health Facilities, General Licensing Standards (6 CCR 1011-1).

Question Title

* 1. Applicant Facility Information

Applicant Facility Name

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 Proposed for the Alternate Care Site