Certificate of Compliance Request

This request form is for existing facilities ONLY. New facilities, facilities that have never been occupied or haven't been occupied in years or facilities that are changing from Private Pay to Certified will need to go through Plan Review either through DFPC, the local Authority Having Jurisdiction or BOTH). If you have questions regarding your facility please email us at cdps_dfpc_coc@state.co.us.

Facility Information

Name of Facility

Street Address of Facility

City of Facility

Zip Code of Facility

Facility ID

CDPHE licensees (e.g., hospitals, ALRs, ASCs) please call 303-692-2000 for assistance with your Facility ID.

For BHA licensees (e.g., outpatient health centers, in-patient substance use residences) please contact BHA_QS_Division@state.co.us or your assigned licensing manager.

Is this an Off Campus Location (OCL)?

YesNo

Please note that all OCL's expire at the same time as the main campus. If you have multiple OCL's please submit them all so your licensure will not be delayed.

Facilities with deficiencies/violations - you must send any questions or corrections to your original inspector.

*Their contact information can be found on your inspection report*

Submitting a CoC request to this form for a facility with outstanding deficiencies will only result in delays.

First Name of Person Submitting Form

Last Name of Person Submitting Form

Email Address

Contact Number

Is the person submitting the form also the billing contact?

Yes, I am the billing contact.No, I will provide billing contact information.No, I do not know billing contact information

Is the billing address the same as the physical address?

YesNo

Keeping your Billing Contact updated ensures that you will receive an invoice for your Certificate of Compliance annual fee as per 8 CCR 1507-13.3.

Billing Address of Facility

Billing City

Billing State

Billing Zip Code

Billing Contact First Name

Billing Contact Last Name

Billing Contact Email Address

Billing Contact Number

Contact Information