Abeyance Request Application

Abeyance Request Application

The Division of Health Planning & Resource Development (HP&RD) requires applicants to submit a completed application with a $500.00 processing fee for a proposed abeyance transaction. Once the Abeyance Request is received by HP&RD, the official process of the request will commence.

Please note that the request will be processed in at least thirty (30) to forty-five (45) days after the application is confirmed received. The Division of Health Facilities Licensure and Certification will confirm the records of the current number of beds in abeyance and update the records to reflect the proposed transaction. Upon completion of analysis, the applicant will receive proper notification to and approval by the Department via email, confirming the proposed abeyance request.

A fee of Five Hundred Dollars ($500.00) shall be assessed for the processing and handling of all abeyance requests and is payable to the Mississippi State Department of Health by check, draft, or money order and should be mailed or hand delivered as well as a copy of the application and/or cover letter to the following address:

Division of Health Planning and Resource Development

Mississippi State Department of Health - Office of Health Protection

143-B Le Fleur’s Square

Jackson, MS 39211

Facility Name*

Facility Location/Address*

Facility License Number*

Primary Contact Name*

Primary Contact Title*

Company/ Organization/Firm*

Contact Phone Number*

Phone

Contact Email Address*

What is the facility’s current number of licensed beds?*

How many beds does the facility currently have in abeyance?*

Is the facility Delicensing (putting beds into abeyance) or Relicensing (taking beds out of abeyance?*

Select or enter value

What type of beds is the facility delicensing/relicensing? (ex. Acute Care; Chemical Dependency; Long-Term Care, etc.)*

Number of beds to be delicensed (put in abeyance) OR Number of beds to be relicensed (taken out of abeyance)*

How many licensed beds will the facility have once the abeyance request is approved*

Please read and certify that you understand these guidelines. By selecting each box, the applicant attests, understands, and agrees to each statement. Failure to agree to one or more statements will result in application ineligibility.

By executing and submitting this application, you attest to the following:

I certify that the above information is true to the best of my knowledge and belief.*

I acknowledge and understand that a Five Hundred Dollars ($500.00) processing fee shall be assessed for the processing and handling of all abeyance requests and the request will be fulfilled within thirty (30) - forty-five (45) days upon receipt of payment.*

I acknowledge and certify that a check, draft, or money order made payable to Mississippi Department of Health, as well as a copy of the application and/or cover letter will be sent to the Division of Health Planning and Resource Development at 143 LeFleur's Square, Jackson, MS 39211.

Date of Request*

Send me a copy of my responses

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