Office of Licensure
Useful Licensure Forms
- TDMHSAS Initial Application for License (MH-4385)
- Application for License Renewal (MH-4457)
- Application Fee Schedule and Invoice (MH-4453)
- TDMHSAS Notification of Civil Penalty MH-5330 Interactive Form (for use by Office of Licensure
staff only) - TDMHSAS Allegation/Suspicion of Neglect/Abuse/Dereliction (MH-5375)
- TDMHSAS Licensure Application Fact Sheet (MH-4386)
- Application Financial Statement (MH-4466)
- Change of Status Form (MH-4454)
- TDMHSAS Title VI Monitoring Guide printable blank form (for use by Office of Licensure staff only)
- MH-5460 Licensure Background Check Information
Licensure and Review Links
Governor Bill Haslam
