State Regulation Waiver Application: Licensed Hospitals for Alternate Care Site (Capacity Increase) Due to COVID-19 Inpatient Needs

1.

PLEASE NOTE: This application should only be used by licensed hospitals and is only for waivers of Colorado state regulations.

The regulations governing the process of granting or denying applications for waiver of regulations pertaining to health facilities in Colorado can be found in Chapter 2, Part 5 of the Department’s Standards for Hospital and Health Facilities, General Licensing Standards (6 CCR 1011-1).

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* 1. Applicant Facility Information

Applicant Facility Name

Applicant Current Facility Type

Applicant Current License #

Applicant Address (# and Street)

Applicant Address (City, State, Zip)

Applicant Facility Administrator Name

Applicant Facility Administrator Telephone Number

Applicant Facility Administrator Email Address

Number of Beds at Alternate Care Facility requested

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* 2. Alternate Care Site Information

Alternate Care Site Name

Alternate Care Site Facility Type

Alternate Care Site License #

Alternate Care Site Address (# and Street)

Alternate Care Site Address (City, State, Zip)

Alternate Care Site Administrator Name

Alternate Care Site Administrator Telephone Number

Alternate Care Site Administrator Email Address

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* 3. Will the Alternate Care Site continue to operate under its current license in some capacity?

**NOTE: If the Alternate Care Site is a licensed Ambulatory Surgical Center or a Community Clinic with Emergency Center, it must cease operating as such during the time that the Applicant Facility provides hospital services.

Yes