Contacts
Division of Health Care Facility Licensure and Certification
The Details of Apply for an Adult Day Health program license
What you need for Apply for an Adult Day Health program license
- An Adult Day Health Program is any entity, however organized, whether conducted for profit or not for profit that:
- Supports families and other caregivers thereby enabling the participant to live in the community
- Provides nursing care, supervision, and health related support services in a structured group setting to persons 18 years of age or older who have physical, cognitive, or behavioral health impairments; and
- Is community-based and non-residential
Applicants for Adult Day Health Program licensure must complete all required documents and any additional documents, as applicable.
How to apply Apply for an Adult Day Health program license
To apply for a license of a new or existing program, use the following forms, as applicable:
- Application Checklist (required form)
- Suitability Form (required form)
- Local Fire Certificate (required attachment)
- CORI Form (DOC) (required attachment)
- Suitability Application Disclosure Form (DOC) (attach only if applicable)
- Program Capacity Form (required form)
- Clinical Information and Attestation Form (required)
- Physical Plant Waiver Request Form (DOC) (attach only if applicable)
- Approved Test Form (attach only if applicable)
- CMS116 Form (attach only if applicable)
- HCFRS Enrollment Forms:
- Form C - HCFRS Facility Agreement (DOC) (required form)
- Form D - HCFRS User Agreement (DOC) (required form for each user)
Programs must include additional documentation as required or applicable as indicated on the Application Checklist.
Mail all completed forms and attachments to:
Licensure Coordinator
Department of Public Health
Division of Health Care Facility Licensure and Certification
67 Forest Street
Marlborough, MA 01752
Contact for Apply for an Adult Day Health program license
Address
67 Forest St., Marlborough, MA 01752