{"id":82,"date":"2016-07-20T21:10:54","date_gmt":"2016-07-20T21:10:54","guid":{"rendered":"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/?page_id=82"},"modified":"2025-12-29T17:16:13","modified_gmt":"2025-12-29T22:16:13","slug":"applications-and-forms","status":"publish","type":"page","link":"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/applications-and-forms\/","title":{"rendered":"Applications &amp; Forms"},"content":{"rendered":"<div id=\"pl-82\"  class=\"panel-layout\" ><div id=\"pg-82-0\"  class=\"panel-grid panel-no-style\" ><div id=\"pgc-82-0-0\"  class=\"panel-grid-cell\" ><div id=\"panel-82-0-0-0\" class=\"so-panel widget widget_sow-editor panel-first-child panel-last-child\" data-index=\"0\" ><div class=\"panel-widget-style panel-widget-style-for-82-0-0-0\" ><div\n\t\t\t\n\t\t\tclass=\"so-widget-sow-editor so-widget-sow-editor-base\"\n\t\t\t\n\t\t>\n<div class=\"siteorigin-widget-tinymce textwidget\">\n\t<p>Phase I of the online application portal for its licensing programs has launched for applications for:<\/p>\n<ul>\n<li>New licenses<\/li>\n<li>Renewal of existing licenses<\/li>\n<li>Exemptions (for hospices and HCOs)<\/li>\n<li>Changes to existing licenses<\/li>\n<\/ul>\n<p>Please use the VDH OLC Portal button to access the new system. Instructions for how to request a user access account are hyperlinked beneath the VDH OLC Portal button<\/p>\n<\/div>\n<\/div><\/div><\/div><\/div><\/div><div id=\"pg-82-1\"  class=\"panel-grid panel-has-style\" ><div class=\"panel-row-style panel-row-style-for-82-1\" ><div id=\"pgc-82-1-0\"  class=\"panel-grid-cell\" ><div id=\"panel-82-1-0-0\" class=\"so-panel widget widget_sow-accordion panel-first-child panel-last-child\" data-index=\"1\" ><div\n\t\t\t\n\t\t\tclass=\"so-widget-sow-accordion so-widget-sow-accordion-default-9283442e76cf-82\"\n\t\t\t\n\t\t><div>\n\t<div class=\"sow-accordion\">\n\t\t\t<div class=\"sow-accordion-panel\n\t\t\t\t\t\"\n\t\t\t\tdata-anchor-id=\"certificate-of-public-need\">\n\t\t\t\t\t<div class=\"sow-accordion-panel-header-container\" role=\"heading\" aria-level=\"2\">\n\t\t\t\t\t<div class=\"sow-accordion-panel-header\" tabindex=\"0\" role=\"button\" id=\"accordion-label-certificate-of-public-need\" aria-controls=\"accordion-content-certificate-of-public-need\" aria-expanded=\"false\">\n\t\t\t\t\t\t<div class=\"sow-accordion-title sow-accordion-title-icon-left\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\tCertificate of Public Need\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"sow-accordion-open-close-button\">\n\t\t\t\t\t\t\t<div class=\"sow-accordion-open-button\">\n\t\t\t\t\t\t\t\t<span class=\"sow-icon-ionicons\" data-sow-icon=\"&#xf218;\"\n\t\t \n\t\taria-hidden=\"true\"><\/span>\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"sow-accordion-close-button\">\n\t\t\t\t\t\t\t\t<span class=\"sow-icon-ionicons\" data-sow-icon=\"&#xf209;\"\n\t\t \n\t\taria-hidden=\"true\"><\/span>\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\n\t\t\t<div\n\t\t\t\tclass=\"sow-accordion-panel-content\"\n\t\t\t\trole=\"region\"\n\t\t\t\taria-labelledby=\"accordion-label-certificate-of-public-need\"\n\t\t\t\tid=\"accordion-content-certificate-of-public-need\"\n\t\t\t\tstyle=\"display: none;\"\t\t\t>\n\t\t\t\t<div class=\"sow-accordion-panel-border\">\n\t\t\t\t\t<h4>Application Forms<\/h4>\n<ul>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2024\/01\/Hospital-application.doc\">Hospital application<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2024\/01\/Outpatient-Facilities-application.doc\">Outpatient Facilities application<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/04\/COPN-NH-Application.doc\" target=\"_blank\" rel=\"noopener noreferrer\">Long Term Care Application<\/a><\/li>\n<\/ul>\n<h4>COPN Long Term Care Forms<\/h4>\n<ul>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2019\/12\/Instructions.doc\">Instructions<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/04\/COPN-Estimated-Costs.xlsx\" target=\"_blank\" rel=\"noopener noreferrer\">Estimated Costs<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/04\/COPN-Faculty-Staffing.doc\" target=\"_blank\" rel=\"noopener noreferrer\">Facility Staffing<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/04\/Revenue-Expense-Statement.xlsx\" target=\"_blank\" rel=\"noopener noreferrer\">Revenue\/Expense Statement<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/04\/TABULATION-OF-SPACE.doc\" target=\"_blank\" rel=\"noopener noreferrer\">Tabulation of Space<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/04\/Bed-Completement.doc\" target=\"_blank\" rel=\"noopener noreferrer\">Bed Complement<\/a><\/li>\n<\/ul>\n<h4>Other Forms<\/h4>\n<ul>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2020\/11\/IFFC-Affidavit-Form-11-17-2020.pdf\">IFFC Affidavit<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2019\/12\/Request-for-Extension-or-Significant-Change.doc\">Request for Extension or Significant Change<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2019\/12\/Registration-of-Major-Medical-Equipment.doc\">Registration of Major Medical Equipment<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2019\/12\/Registration-of-Major-Capital-Expenditure.doc\">Registration of Major Capital Expenditure<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2019\/11\/OLC-1006-F-Request-for-Disaster-Exemption.pdf\">Request for Disaster Exemption<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2019\/11\/OLC-1007-F-Notification-of-Utilization-of-Disaster-Exemption.pdf\">Notification of Utilization of Disaster Exemption<\/a><\/li>\n<\/ul>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t<div class=\"sow-accordion-panel\n\t\t\t\t\t\"\n\t\t\t\tdata-anchor-id=\"complaints\">\n\t\t\t\t\t<div class=\"sow-accordion-panel-header-container\" role=\"heading\" aria-level=\"2\">\n\t\t\t\t\t<div class=\"sow-accordion-panel-header\" tabindex=\"0\" role=\"button\" id=\"accordion-label-complaints\" aria-controls=\"accordion-content-complaints\" aria-expanded=\"false\">\n\t\t\t\t\t\t<div class=\"sow-accordion-title sow-accordion-title-icon-left\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\tComplaints\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"sow-accordion-open-close-button\">\n\t\t\t\t\t\t\t<div class=\"sow-accordion-open-button\">\n\t\t\t\t\t\t\t\t<span class=\"sow-icon-ionicons\" data-sow-icon=\"&#xf218;\"\n\t\t \n\t\taria-hidden=\"true\"><\/span>\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"sow-accordion-close-button\">\n\t\t\t\t\t\t\t\t<span class=\"sow-icon-ionicons\" data-sow-icon=\"&#xf209;\"\n\t\t \n\t\taria-hidden=\"true\"><\/span>\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\n\t\t\t<div\n\t\t\t\tclass=\"sow-accordion-panel-content\"\n\t\t\t\trole=\"region\"\n\t\t\t\taria-labelledby=\"accordion-label-complaints\"\n\t\t\t\tid=\"accordion-content-complaints\"\n\t\t\t\tstyle=\"display: none;\"\t\t\t>\n\t\t\t\t<div class=\"sow-accordion-panel-border\">\n\t\t\t\t\t<ul>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/Provider-Facility-Complaint-Form.docx\">Provider or Facility Complaint Form<\/a><\/li>\n<\/ul>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t<div class=\"sow-accordion-panel\n\t\t\t\t\t\"\n\t\t\t\tdata-anchor-id=\"home-care\">\n\t\t\t\t\t<div class=\"sow-accordion-panel-header-container\" role=\"heading\" aria-level=\"2\">\n\t\t\t\t\t<div class=\"sow-accordion-panel-header\" tabindex=\"0\" role=\"button\" id=\"accordion-label-home-care\" aria-controls=\"accordion-content-home-care\" aria-expanded=\"false\">\n\t\t\t\t\t\t<div class=\"sow-accordion-title sow-accordion-title-icon-left\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\tHome Care\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"sow-accordion-open-close-button\">\n\t\t\t\t\t\t\t<div class=\"sow-accordion-open-button\">\n\t\t\t\t\t\t\t\t<span class=\"sow-icon-ionicons\" data-sow-icon=\"&#xf218;\"\n\t\t \n\t\taria-hidden=\"true\"><\/span>\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"sow-accordion-close-button\">\n\t\t\t\t\t\t\t\t<span class=\"sow-icon-ionicons\" data-sow-icon=\"&#xf209;\"\n\t\t \n\t\taria-hidden=\"true\"><\/span>\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\n\t\t\t<div\n\t\t\t\tclass=\"sow-accordion-panel-content\"\n\t\t\t\trole=\"region\"\n\t\t\t\taria-labelledby=\"accordion-label-home-care\"\n\t\t\t\tid=\"accordion-content-home-care\"\n\t\t\t\tstyle=\"display: none;\"\t\t\t>\n\t\t\t\t<div class=\"sow-accordion-panel-border\">\n\t\t\t\t\t<h4>Application Forms<\/h4>\n<p>Use the <a href=\"https:\/\/vita-vdh.my.site.com\/olcportal\">VDH OLC Portal<\/a> to:<\/p>\n<ul>\n<li>Apply for a new license<\/li>\n<li>Renew an existing license<\/li>\n<li>Request an exemption<\/li>\n<li>Report changes to your licensing record (e.g., change of name, location, etc.)<\/li>\n<\/ul>\n<h4>Other Forms<\/h4>\n<ul>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2019\/09\/Acute-care-facility-response-form.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Acute Care Facility Response Form<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/04\/Consent-Home-Visit-1.doc\">Consent for Home Visit<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/04\/HHA-Branch-Request.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Home Care Organization Branch Request<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2020\/12\/OLC-3001-F-Mandatory-Report-of-Home-Care-Organization-Home-Health-Agency-and-Hospice-Employees.pdf\">Mandatory Report of Home Care Organization, Home Health Agency, and Hospice Employees<\/a><\/li>\n<\/ul>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t<div class=\"sow-accordion-panel\n\t\t\t\t\t\"\n\t\t\t\tdata-anchor-id=\"hospice\">\n\t\t\t\t\t<div class=\"sow-accordion-panel-header-container\" role=\"heading\" aria-level=\"2\">\n\t\t\t\t\t<div class=\"sow-accordion-panel-header\" tabindex=\"0\" role=\"button\" id=\"accordion-label-hospice\" aria-controls=\"accordion-content-hospice\" aria-expanded=\"false\">\n\t\t\t\t\t\t<div class=\"sow-accordion-title sow-accordion-title-icon-left\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\tHospice\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"sow-accordion-open-close-button\">\n\t\t\t\t\t\t\t<div class=\"sow-accordion-open-button\">\n\t\t\t\t\t\t\t\t<span class=\"sow-icon-ionicons\" data-sow-icon=\"&#xf218;\"\n\t\t \n\t\taria-hidden=\"true\"><\/span>\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"sow-accordion-close-button\">\n\t\t\t\t\t\t\t\t<span class=\"sow-icon-ionicons\" data-sow-icon=\"&#xf209;\"\n\t\t \n\t\taria-hidden=\"true\"><\/span>\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\n\t\t\t<div\n\t\t\t\tclass=\"sow-accordion-panel-content\"\n\t\t\t\trole=\"region\"\n\t\t\t\taria-labelledby=\"accordion-label-hospice\"\n\t\t\t\tid=\"accordion-content-hospice\"\n\t\t\t\tstyle=\"display: none;\"\t\t\t>\n\t\t\t\t<div class=\"sow-accordion-panel-border\">\n\t\t\t\t\t<h4>Application Forms<\/h4>\n<p>Use the <a href=\"https:\/\/vita-vdh.my.site.com\/olcportal\">VDH OLC Portal<\/a> to:<\/p>\n<ul>\n<li>Apply for a new license<\/li>\n<li>Renew an existing license<\/li>\n<li>Request an exemption<\/li>\n<li>Report changes to your licensing record (e.g., change of name, location, etc.)<\/li>\n<\/ul>\n<h4>Other Forms<\/h4>\n<ul>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2019\/09\/Acute-care-facility-response-form.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Acute Care Facility Response Form<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/04\/Consent-Home-Visit-1.doc\">Consent for Home Visit<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2019\/03\/Facility-Reported-Incident.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Facility Reported Incident Form<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2020\/12\/OLC-3001-F-Mandatory-Report-of-Home-Care-Organization-Home-Health-Agency-and-Hospice-Employees.pdf\">Mandatory Report of Home Care Organization, Home Health Agency, and Hospice Employees<\/a><\/li>\n<\/ul>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t<div class=\"sow-accordion-panel\n\t\t\t\t\t\"\n\t\t\t\tdata-anchor-id=\"hospital\">\n\t\t\t\t\t<div class=\"sow-accordion-panel-header-container\" role=\"heading\" aria-level=\"2\">\n\t\t\t\t\t<div class=\"sow-accordion-panel-header\" tabindex=\"0\" role=\"button\" id=\"accordion-label-hospital\" aria-controls=\"accordion-content-hospital\" aria-expanded=\"false\">\n\t\t\t\t\t\t<div class=\"sow-accordion-title sow-accordion-title-icon-left\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\tHospital\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"sow-accordion-open-close-button\">\n\t\t\t\t\t\t\t<div class=\"sow-accordion-open-button\">\n\t\t\t\t\t\t\t\t<span class=\"sow-icon-ionicons\" data-sow-icon=\"&#xf218;\"\n\t\t \n\t\taria-hidden=\"true\"><\/span>\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"sow-accordion-close-button\">\n\t\t\t\t\t\t\t\t<span class=\"sow-icon-ionicons\" data-sow-icon=\"&#xf209;\"\n\t\t \n\t\taria-hidden=\"true\"><\/span>\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\n\t\t\t<div\n\t\t\t\tclass=\"sow-accordion-panel-content\"\n\t\t\t\trole=\"region\"\n\t\t\t\taria-labelledby=\"accordion-label-hospital\"\n\t\t\t\tid=\"accordion-content-hospital\"\n\t\t\t\tstyle=\"display: none;\"\t\t\t>\n\t\t\t\t<div class=\"sow-accordion-panel-border\">\n\t\t\t\t\t<h4>Application Forms<\/h4>\n<p>Use the <a href=\"https:\/\/vita-vdh.my.site.com\/olcportal\">VDH OLC Portal<\/a> to:<\/p>\n<ul>\n<li>Apply for a new license<\/li>\n<li>Renew an existing license<\/li>\n<li>Report changes to your licensing record (e.g., change of name, location, etc.)<\/li>\n<\/ul>\n<h4>Other Forms<\/h4>\n<ul type=\"disc\">\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2019\/03\/Facility-Reported-Incident.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Facility Reported Incident Form<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2019\/09\/Acute-care-facility-response-form.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Acute Care Facility Response Form<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/04\/Model-Universal-Transfer-Form.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Model Universal Transfer Form<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/04\/Transfer-Form-Summary.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Model Universal Transfer Summary<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2019\/11\/OLC-1006-F-Request-for-Disaster-Exemption.pdf\">Request for Disaster Exemption<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2019\/11\/OLC-1007-F-Notification-of-Utilization-of-Disaster-Exemption.pdf\">Notification of Utilization of Disaster Exemption<\/a><\/li>\n<\/ul>\n<p><strong>Other Resources<\/strong><\/p>\n<ul>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2023\/06\/Checklist-SAS-Transfer.pdf\">Checklist - Adult Sexual Assault Survivor Transfer Plan<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2023\/06\/Checklist-SAS-Treatment.pdf\">Checklist - Adult Sexual Assault Survivor Treatment Plan<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2023\/06\/Checklist-PSAS-Treatment-Partial.pdf\">Checklist - Pediatric Sexual Assault Survivor Treatment Plan (partial range of treatment services offered to pediatric patients)<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2023\/06\/Checklist-PSAS-Treatment-Full.pdf\">Checklist - Pediatric Sexual Assault Survivor Treatment Plan (full\u00a0range of treatment services offered to pediatric patients)<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2023\/06\/Checklist-PSAS-Transfer.pdf\">Checklist - Pediatric Sexual Assault Survivor Transfer Plan<\/a><\/li>\n<\/ul>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t<div class=\"sow-accordion-panel\n\t\t\t\t\t\"\n\t\t\t\tdata-anchor-id=\"managed-care-health-insurance-plan-and-private-review-agent\">\n\t\t\t\t\t<div class=\"sow-accordion-panel-header-container\" role=\"heading\" aria-level=\"2\">\n\t\t\t\t\t<div class=\"sow-accordion-panel-header\" tabindex=\"0\" role=\"button\" id=\"accordion-label-managed-care-health-insurance-plan-and-private-review-agent\" aria-controls=\"accordion-content-managed-care-health-insurance-plan-and-private-review-agent\" aria-expanded=\"false\">\n\t\t\t\t\t\t<div class=\"sow-accordion-title sow-accordion-title-icon-left\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\tManaged Care Health Insurance Plan and Private Review Agent\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"sow-accordion-open-close-button\">\n\t\t\t\t\t\t\t<div class=\"sow-accordion-open-button\">\n\t\t\t\t\t\t\t\t<span class=\"sow-icon-ionicons\" data-sow-icon=\"&#xf218;\"\n\t\t \n\t\taria-hidden=\"true\"><\/span>\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"sow-accordion-close-button\">\n\t\t\t\t\t\t\t\t<span class=\"sow-icon-ionicons\" data-sow-icon=\"&#xf209;\"\n\t\t \n\t\taria-hidden=\"true\"><\/span>\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\n\t\t\t<div\n\t\t\t\tclass=\"sow-accordion-panel-content\"\n\t\t\t\trole=\"region\"\n\t\t\t\taria-labelledby=\"accordion-label-managed-care-health-insurance-plan-and-private-review-agent\"\n\t\t\t\tid=\"accordion-content-managed-care-health-insurance-plan-and-private-review-agent\"\n\t\t\t\tstyle=\"display: none;\"\t\t\t>\n\t\t\t\t<div class=\"sow-accordion-panel-border\">\n\t\t\t\t\t<h4>Application Forms<\/h4>\n<ul type=\"disc\">\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2019\/11\/Application-for-a-Certificate-of-Quality-Assurance.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Application for a Certificate of Quality Assurance<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2020\/03\/Questions-to-Exclude-Based-on-NCQA-Certification.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Questions to Exclude Based on NCQA Certification<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/04\/PRA-Application.doc\" target=\"_blank\" rel=\"noopener noreferrer\">Private Review Agent Application<\/a><\/li>\n<\/ul>\n<h4>Other Forms<\/h4>\n<ul type=\"disc\">\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2019\/11\/Geographic-Service-Area-Change-Worksheet-1.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">MCHIP Geographic Service Area Change Worksheet<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/04\/MCHIP-Enrollee-Complaint-Form.doc\" target=\"_blank\" rel=\"noopener noreferrer\">MCHIP Enrollee Complaint Form<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/04\/MCHIP-Annual-Complaint-Form.doc\" target=\"_blank\" rel=\"noopener noreferrer\">MCHIP Annual Complaint Form<\/a><\/li>\n<\/ul>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t<div class=\"sow-accordion-panel\n\t\t\t\t\t\"\n\t\t\t\tdata-anchor-id=\"nursing-home\">\n\t\t\t\t\t<div class=\"sow-accordion-panel-header-container\" role=\"heading\" aria-level=\"2\">\n\t\t\t\t\t<div class=\"sow-accordion-panel-header\" tabindex=\"0\" role=\"button\" id=\"accordion-label-nursing-home\" aria-controls=\"accordion-content-nursing-home\" aria-expanded=\"false\">\n\t\t\t\t\t\t<div class=\"sow-accordion-title sow-accordion-title-icon-left\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\tNursing Home\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"sow-accordion-open-close-button\">\n\t\t\t\t\t\t\t<div class=\"sow-accordion-open-button\">\n\t\t\t\t\t\t\t\t<span class=\"sow-icon-ionicons\" data-sow-icon=\"&#xf218;\"\n\t\t \n\t\taria-hidden=\"true\"><\/span>\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"sow-accordion-close-button\">\n\t\t\t\t\t\t\t\t<span class=\"sow-icon-ionicons\" data-sow-icon=\"&#xf209;\"\n\t\t \n\t\taria-hidden=\"true\"><\/span>\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\n\t\t\t<div\n\t\t\t\tclass=\"sow-accordion-panel-content\"\n\t\t\t\trole=\"region\"\n\t\t\t\taria-labelledby=\"accordion-label-nursing-home\"\n\t\t\t\tid=\"accordion-content-nursing-home\"\n\t\t\t\tstyle=\"display: none;\"\t\t\t>\n\t\t\t\t<div class=\"sow-accordion-panel-border\">\n\t\t\t\t\t<h4>Application Forms<\/h4>\n<ul type=\"disc\">\n<li>Use the <a href=\"https:\/\/vita-vdh.my.site.com\/olcportal\">VDH OLC Portal<\/a> to:\n<ul>\n<li>Apply for a new license<\/li>\n<li>Renew an existing license<\/li>\n<li>Report changes to your licensing record (e.g., change of name, location, etc.)<\/li>\n<\/ul>\n<\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/04\/ePOC-steps-for-facility.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">e-Plan of Correction (ePOC) Application Information<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/04\/feed-hydration-program-application.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Application for Feeding Hydration Program<\/a><\/li>\n<\/ul>\n<h4>Other\u00a0Forms<\/h4>\n<ul>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/04\/Bed-Change-Form.xls\" target=\"_blank\" rel=\"noopener noreferrer\">Bed Change Form<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2022\/07\/LTC-facility-survey-response-form.pdf\">LTC Facility Survey Response Form<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2019\/03\/Facility-Reported-Incident.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Facility Reported Incident Form<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/08\/Informal-Dispute-Resolution-Process.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Informal Dispute Resolution (IDR)\u00a0Process<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/10\/Independent-IDR-Process.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Independent-IDR-Process<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/04\/ExtendedCareFacilityResponseGuideline.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Extended Care Facility Response Guideline<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/04\/Model-Universal-Transfer-Form.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Model Universal Transfer Form<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/04\/Transfer-Form-Summary.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Model Universal Transfer Summary<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2018\/04\/Payroll-Based-Journal-System.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Payroll Based Journal System<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2021\/08\/Public-Directory.pdf\" target=\"_blank\" rel=\"noopener\">Public Directory [updated 7\/2021]<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2019\/11\/OLC-1006-F-Request-for-Disaster-Exemption.pdf\">Request for Disaster Exemption<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2019\/11\/OLC-1007-F-Notification-of-Utilization-of-Disaster-Exemption.pdf\">Notification of Utilization of Disaster Exemption<\/a><\/li>\n<\/ul>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/div>\n<\/div>\n<\/div><\/div><\/div><div id=\"pgc-82-1-1\"  class=\"panel-grid-cell\" ><div id=\"panel-82-1-1-0\" class=\"so-panel widget widget_siteorigin-panels-builder panel-first-child panel-last-child\" data-index=\"2\" ><div class=\"panel-widget-style panel-widget-style-for-82-1-1-0\" ><div id=\"pl-w65b28a8aab641\"  class=\"panel-layout\" ><div id=\"pg-w65b28a8aab641-0\"  class=\"panel-grid panel-no-style\" ><div id=\"pgc-w65b28a8aab641-0-0\"  class=\"panel-grid-cell\" ><div id=\"panel-w65b28a8aab641-0-0-0\" class=\"so-panel widget widget_sow-headline panel-first-child\" data-index=\"0\" ><div class=\"panel-widget-style panel-widget-style-for-w65b28a8aab641-0-0-0\" ><div\n\t\t\t\n\t\t\tclass=\"so-widget-sow-headline so-widget-sow-headline-default-1138ec691836 so-widget-fittext-wrapper\"\n\t\t\t data-fit-text-compressor=\"0.85\"\n\t\t><div class=\"sow-headline-container \">\n\t\t\t\t\t\t\t<h3 class=\"sow-headline\">\n\t\t\t\t\t\tClick below to access application portal\t\t\t\t\t\t<\/h3>\n\t\t\t\t\t\t<\/div>\n<\/div><\/div><\/div><div id=\"panel-w65b28a8aab641-0-0-1\" class=\"so-panel widget widget_sow-button\" data-index=\"1\" ><div\n\t\t\t\n\t\t\tclass=\"so-widget-sow-button so-widget-sow-button-atom-800e9005f87b\"\n\t\t\t\n\t\t><div class=\"ow-button-base ow-button-align-center\"\n>\n\t\t\t<a\n\t\t\t\t\thref=\"https:\/\/vita-vdh.my.site.com\/olcportal\"\n\t\t\t\t\tclass=\"sowb-button ow-icon-placement-left ow-button-hover\" \t>\n\t\t<span>\n\t\t\t\n\t\t\tVDH OLC Portal\t\t<\/span>\n\t\t\t<\/a>\n\t<\/div>\n<\/div><\/div><div id=\"panel-w65b28a8aab641-0-0-2\" class=\"so-panel widget widget_sow-editor panel-last-child\" data-index=\"2\" ><div\n\t\t\t\n\t\t\tclass=\"so-widget-sow-editor so-widget-sow-editor-base\"\n\t\t\t\n\t\t>\n<div class=\"siteorigin-widget-tinymce textwidget\">\n\t<h5><em>NOTE: This portal is for licensing only. Applicants for COPN, MCHIP, and PRA should continue to use the applications linked on this page and pay via check or money order.<\/em><\/h5>\n<ul>\n<li>If you are a new user WITHOUT A LICENSE, please follow these \"<strong><span style=\"text-decoration: underline\"><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2023\/06\/Requesting-User-Access-as-an-Applicant-for-Licensure.pdf\">Requesting User Access as an Applicant for Licensure<\/a><\/span><\/strong>\"\u00a0instructions to request a user access account.<\/li>\n<li>If you have a license and only have one licensed facility\/agency, please follow these \"<span style=\"text-decoration: underline\"><strong><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2023\/06\/Requesting-User-Access-as-an-Existing-Licensee.pdf\">Requesting User Access as an Existing Licensee<\/a><\/strong><\/span>\" instructions to request a user access account.<\/li>\n<li>If you have a license and have multiple licensed facilities\/agencies, please follow these \"<span style=\"text-decoration: underline\"><strong><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/96\/2023\/06\/Requesting-User-Access-for-Multiple-Facilities.pdf\">Requesting User Access for Multiple Facilities\/Agencies<\/a><\/strong><\/span>\" instructions to request a user access account.<\/li>\n<li>If you are a returning user (i.e., you already have a user access account), click the button above and select \"Login\" in the upper right hand corner of the portal, then login in with your username and password.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<\/div>\n<\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div>","protected":false},"excerpt":{"rendered":"<p>Phase I of the online application portal for its licensing programs has launched for applications for: New licenses Renewal of existing licenses Exemptions (for hospices and HCOs) Changes to existing licenses Please use the VDH OLC Portal button to access the new system. Instructions for how to request a user access account are hyperlinked beneath [&hellip;]<\/p>\n","protected":false},"author":637,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_lmt_disableupdate":"no","_lmt_disable":"","footnotes":""},"tags":[],"class_list":["post-82","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Applications &amp; Forms - Licensure And Certification<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/applications-and-forms\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Applications &amp; Forms - Licensure And Certification\" \/>\n<meta property=\"og:description\" content=\"Phase I of the online application portal for its licensing programs has launched for applications for: New licenses Renewal of existing licenses Exemptions (for hospices and HCOs) Changes to existing licenses Please use the VDH OLC Portal button to access the new system. Instructions for how to request a user access account are hyperlinked beneath [&hellip;]\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/applications-and-forms\/\" \/>\n<meta property=\"og:site_name\" content=\"Licensure And Certification\" \/>\n<meta property=\"article:modified_time\" content=\"2025-12-29T22:16:13+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"3 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/www.vdh.virginia.gov\\\/licensure-and-certification\\\/applications-and-forms\\\/\",\"url\":\"https:\\\/\\\/www.vdh.virginia.gov\\\/licensure-and-certification\\\/applications-and-forms\\\/\",\"name\":\"Applications &amp; Forms - Licensure And Certification\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/www.vdh.virginia.gov\\\/licensure-and-certification\\\/#website\"},\"datePublished\":\"2016-07-20T21:10:54+00:00\",\"dateModified\":\"2025-12-29T22:16:13+00:00\",\"breadcrumb\":{\"@id\":\"https:\\\/\\\/www.vdh.virginia.gov\\\/licensure-and-certification\\\/applications-and-forms\\\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/www.vdh.virginia.gov\\\/licensure-and-certification\\\/applications-and-forms\\\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/www.vdh.virginia.gov\\\/licensure-and-certification\\\/applications-and-forms\\\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\\\/\\\/www.vdh.virginia.gov\\\/licensure-and-certification\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Applications &amp; Forms\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\\\/\\\/www.vdh.virginia.gov\\\/licensure-and-certification\\\/#website\",\"url\":\"https:\\\/\\\/www.vdh.virginia.gov\\\/licensure-and-certification\\\/\",\"name\":\"Licensure And Certification\",\"description\":\"\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\\\/\\\/www.vdh.virginia.gov\\\/licensure-and-certification\\\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Applications &amp; Forms - Licensure And Certification","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/applications-and-forms\/","og_locale":"en_US","og_type":"article","og_title":"Applications &amp; Forms - Licensure And Certification","og_description":"Phase I of the online application portal for its licensing programs has launched for applications for: New licenses Renewal of existing licenses Exemptions (for hospices and HCOs) Changes to existing licenses Please use the VDH OLC Portal button to access the new system. Instructions for how to request a user access account are hyperlinked beneath [&hellip;]","og_url":"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/applications-and-forms\/","og_site_name":"Licensure And Certification","article_modified_time":"2025-12-29T22:16:13+00:00","twitter_card":"summary_large_image","twitter_misc":{"Est. reading time":"3 minutes"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/applications-and-forms\/","url":"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/applications-and-forms\/","name":"Applications &amp; Forms - Licensure And Certification","isPartOf":{"@id":"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/#website"},"datePublished":"2016-07-20T21:10:54+00:00","dateModified":"2025-12-29T22:16:13+00:00","breadcrumb":{"@id":"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/applications-and-forms\/#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/applications-and-forms\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/applications-and-forms\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/"},{"@type":"ListItem","position":2,"name":"Applications &amp; Forms"}]},{"@type":"WebSite","@id":"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/#website","url":"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/","name":"Licensure And Certification","description":"","potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"en-US"}]}},"_links":{"self":[{"href":"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/wp-json\/wp\/v2\/pages\/82","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/wp-json\/wp\/v2\/users\/637"}],"replies":[{"embeddable":true,"href":"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/wp-json\/wp\/v2\/comments?post=82"}],"version-history":[{"count":22,"href":"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/wp-json\/wp\/v2\/pages\/82\/revisions"}],"predecessor-version":[{"id":24664,"href":"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/wp-json\/wp\/v2\/pages\/82\/revisions\/24664"}],"wp:attachment":[{"href":"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/wp-json\/wp\/v2\/media?parent=82"}],"wp:term":[{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.vdh.virginia.gov\/licensure-and-certification\/wp-json\/wp\/v2\/tags?post=82"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}