Apply by Mail

Use the following chart as a guideline when applying, renewing or amending a license.

	Initial Application	Renewal Application	Amendment Application
Fill out necessary forms	HEA5134	Renewal Application Mailed to facility	HEA5135
Application Fee	$300	$300	$150 (when applicable)
Fire and Inspection Report (within last 12 months)	X	X	(address change or building renovation only)
Use and Occupancy Report	X		(address change or building renovation only)
Notarized Affidavit (required when someone other than an owner signs application)	X	X	X
Renewal Notice mailed to you.		X

Mail to:
Ohio Department of Health
Health Care Facility Program
Attn: Revenue Processing - 3600
P.O. Box 15278
Columbus, OH 43215

Telephone: (614) 644-2727