Change Form for Home Health Agency

Change Form Signatures

There will be 2 required signatures on the change form. The administrator of the facility shall not sign the change form unless he/she is also a board member. The change form must be signed by official(s) of the entity responsible for the operation of the facility. (If sole proprietorship, the owner shall sign the change form; if a corporation, two of its officers shall sign; if a state, county, or municipal unit, the change form is to be signed by the head of the department having jurisdiction over the facility.)

Approval Process

Once you have submitted the change form, it will be sent for approval. Once the change form has been reviewed and approved, the contact for the facility will receive an email letting them know it has been approved. The facility may then go to the website and print an updated license. The license will reflect the updated information.