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Revised:05/2024
PUBLIC HEALTH DIVISION
Health Care Regulation and Quality Improvement Section
Health Facility Licensing and Certification Program
healthoregon.org/hflc
In-Home Care Agency License Application Form
Type of Action
New Agency*:
Parent Subunit (provide name of parent agency and city where located. In
addition, attach separate document identifying all subunits associated with the
parent agency)
:
License Renewal*:
License #:
Renewal application must be submitted at least 30 days prior to license expiration date
(OAR 333-536-0025).
Change Request Effective Date of
Change
Change Request Effective Date of
Change
Name Address
Service Area**
Ownership*
Administrator**
Add/Remove Branch**
Classification* **
Other (specify):
* Fee Payment Required (See back of this form for amount) **Requires Public Health Division pre-approval
Agency Information
Agency Legal Name:
Agency DBA Name (if applicable):
Agency Physical Address, City, State & ZIP:
Phone: Fax: County:
Agency Mailing Address (if different from above):
Name of Administrator: Phone:
Administrator E-mail: Agency E-mail:
Does the administrator have direct contact with any client as
defined in OAR 333-536-0093? (If yes, attach ‘IHC Background
Check Request’ form for each administrator having direct contact.)
☐Yes
☐
No
Name of Owner(s) (attach additional pages if necessary):
Owner(s) Email:
Tax ID#:
Address, City, State & ZIP of Owner(s):
Phone: FAX: County:
Does any owner have direct contact with any client as defined
in OAR 333-536-0093? (If yes, attach ‘IHC Background Check
Request’ form for each owner having direct contact.)
☐Yes
☐No
Emergency Contact Name: Emergency Contact Phone: Emergency Contact Email:
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Revised:05/2024
Agency physically located within:
Commercial Business Building Private Home/Residence
Independent Living Retirement
Facility or Community
Registered Continuing Care
Retirement Community
Other Licensed Facility or
Agency Type:
Office
Hours:
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Classification Levels:
New agency
License
renewal/current
classification
Change to
Limited:
An agency that provides personal care services
that may include medication reminding but does not provide
medication assistance, medication administration, or nursing
services.
Basic:
An agency that provides personal care services that
may include medication reminding and medication
assistance but does not provide medication administration or
nursing services.
Intermediate
: An agency that provides personal care
services that may include medication reminding, medication
assistance and medication administration but does not
provide nursing services.
Comprehensive:
An agency that provides personal
care services that may include medication reminding,
medication assistance, medication administration and
nursing services
.
Administrator Designee, Qualified Individual/Entity/Trainer, &/or RN (all classification types)
Administrator Designee Name:
Administrator Designee Title:
Qualified Trainer(s) Name:
Qualified Entity Name:
Qualified Individual Name:
Qualified Individual Title:
Registered Nurse Name (intermediate/comprehensive only):
Description of Branch Operations – use separate sheet if necessary
•
List address and telephone numbers of each branch
•
If this is a change, indicate (A) if adding, (R) if removing, or blank if no change
Please check
A or R
Address Phone
A
R
A
R
A
R
Geographic Service Area:
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Revised:05/2024
I declare, under penalties of perjury, that I have examined this application and all attachments and that to the best of
my knowledge and belief, this information is true, correct, and complete. I will notify the Health Care Regulation and
Quality Improvement Section, in writing, of any changes in this information as required.
Administrator’s
Signature Print Name
Print Title
Date (mm/dd/yyyy)
ALL APPLICATION FEES ARE NON-REFUNDABLE per OAR 333-536-0031(4)
In-Home Care Fees (as of January 1, 2018)
Initial Parent Licensure
Limited $2,000
Basic $2,250
Intermediate $2,500
Comprehensive $3,000
Initial Subunit Licensure All classification types $1,250
Yearly Parent Renewal
Limited $1,000
Basic $1,000
Intermediate $1,250
Comprehensive $1,500
Yearly Subunit Renewal
All classification types
$1,000
Ownership Change $350
Subunit Ownership Change $350
Make check payable to:
Mail payment to:
Oregon Health Authority
HFLC
PO Box 14260
Portland, OR 97293
Questions about this application?
Phone: 971-673-0540 (Option 3)
Email: mailbox.inhom[email protected]egon.gov
HCRQI Office Use Only
Effective date of initial licensure: Class: Initials: Date:
Renewal Licensure/Change: Approved: Denied: Withdrawn: Initials: Date:
CASH OFFICE: QC 659 initial/QC 660 renewal
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Revised:05/2024
Initial (New Agency) Licensure Application Checklist
New Agencies must fill out this checklist and include it with their initial packet, along with the application,
fee, administrator resume, and outlined policies and procedures:
Completely fill out an in-home care application
Include a check or money order payable to the “Oregon Health Authority”
Complete the Owner/Administrator Background Check Request form(s), include a resume and
administrator application form (available at www.healthoregon.org/hflc. Please ensure that your
administrator application and resume meets the following requirements:
• Must show evidence of at least two years of professional or management experience in a health-
related field or program (Please include the employer’s name and location, the dates of employment
including month and year, the title of the position held, and the duties performed); and
• Must show evidence of high school diploma or equivalent
Develop agency specific policies and procedures (including associated forms such as the initial
assessment form, disclosure form, etc.) to address and ensure compliance with the IHC OAR’s,
Division 536. Include the following sampling of those policies, procedures, forms that demonstrate
compliance with the following requirements:
• OAR 333-536-0050 Agency Organization
• OAR 333-536-0055 Disclosure Statement
• OAR 333-536-0065 Service Plan
Send documents listed above to “HFLC, PO BOX 14260, Portland, OR 97293, Attention: IHC Program”.
Partial or incomplete applications will not be processed.
