Health Care Employment Agency Registration

The department's new health care employment agency rules implementing House File 2521, passed by the 89th General Assembly went into effect on Jan. 4, 2023.

The rules require all existing health care employment agencies to register once per year with the department.
In place of completing this form, the same information may be faxed to 515.242.5022, or mailed to:

Iowa Department of Inspections, Appeals, and Licensing
Health & Safety Division
6200 Park Avenue, Suite 100
Des Moines, Iowa 50321
In addition to completing this form, a payment of $500 per health care employment agency office location operating in Iowa should be sent to the mailing address above (and made payable to the same). Please include the confirmation number you receive after submitting this form along with your payment. There is not an option to submit this payment electronically, however, it is anticipated the department will be able to accept electronic payments in the future.
You will not be officially registered until both your registration and payment are received and processed by the department. You will receive an email confirmation after your payment is processed and you have been added to the database.
Please note this is not a license. You will not receive a certificate. The email your agency contact receives from DIA is the confirmation of your registration. Your registration expires after one year from the date of registration.
You only need to register once per year. Please do not complete the registration form multiple times within one year. This may slow down your registration as it will need to be manually corrected.
You will need to complete a quarterly report each quarter that you are registered, regardless of whether or not you have qualifying hired staff within the state that quarter.

Name

Location(s)

This form will allow you to register up to five employment agency office locations at a time. If you have more than five locations, you will need to complete another form.

Do you need to register a second location?

Yes

Do you need to register a third location?

Yes

Do you need to register a fourth location?

Yes

Do you need to register a fifth location?

Yes

Owners/Managing Entities

To prevent delays in communications from DIAL, the person who you list as the first managing entity will be the contact person in the DIAL website and the one to whom communications will be sent. Therefore, you should choose someone who will be managing your agency's information.

Owner/Managing Entity

Owner/Managing Entity 1 contact

Owner/Managing Entity 1 phone

Owner/Managing Entity 1 alternate phone

Owner/Managing Entity 1 email

PLEASE NOTE that the email used in the field above will be used in official communications with the department and will also be the email needed to log in to the Health Facilities database. Please do not enter an email that is used as a distribution list or that is accessible by multiple persons; the email should be an address accessible by one person who will act as the company's administrator.

Do you need to report a second owner/managing entity?

Yes

Owner/Managing Entity 2

Owner/Managing Entity 2 contact

Owner/Managing Entity 2 phone

Owner/Managing Entity 2 alternate phone

Owner/Managing Entity 2 email

Do you need to report a third owner/managing entity?

Yes

Owner/Managing Entity 3

Owner/Managing Entity 3 contact

Owner/Managing Entity 3 phone

Owner/Managing Entity 3 alternate phone

Owner/Managing Entity 3 email

Do you need to report a fourth owner/managing entity?

Yes

Owner/Managing Entity 4

Owner/Managing Entity 4 contact

Owner/Managing Entity 4 phone

Owner/Managing Entity 4 alternate phone

Owner/Managing Entity 4 email

Do you need to report a fifth owner/managing entity?

Yes

Owner/Managing Entity 5

Owner/Managing Entity 5 contact

Owner/Managing Entity 5 phone

Owner/Managing Entity 5 alternate phone

Owner/Managing Entity 5 email

Do you need to report a sixth owner/managing entity?

Yes

Owner/Managing Entity 6

Owner/Managing Entity 6 contact

Owner/Managing Entity 6 phone

Owner/Managing Entity 6 alternate phone

Owner/Managing Entity 6 email

Do you need to report a seventh owner/managing entity?

Yes

Owner/Managing Entity 7

Owner/Managing Entity 7 contact

Owner/Managing Entity 7 phone

Owner/Managing Entity 7 alternate phone

Owner/Managing Entity 7 email

Do you need to report an eighth owner/managing entity?

Yes

Owner/Managing Entity 8

Owner/Managing Entity 8 contact

Owner/Managing Entity 8 phone

Owner/Managing Entity 8 alternate phone

Owner/Managing Entity 8 email

Additional info

Submission and payment

Submission #

You will be provided with a Submission # upon submission.

Thank you for registering.

For each health care employment agency location operating in Iowa, a payment of $500 should be sent to (and checks should be made out to):

Iowa Department of Inspections, Appeals, and Licensing
Health Facilities Division
6200 Park Avenue, Suite 100
Des Moines, Iowa 50321

You will need to send the department $500 for one health care employment agency location.

You will need to send the department $1,000 for two health care employment agency locations.

You will need to send the department $1,500 for three health care employment agency locations.

You will need to send the department $2,000 for four health care employment agency locations.

You will need to send the department $2,500 for five health care employment agency locations.

PLEASE NOTE

You are registering with the department only. You will not receive a "license" or certificate. Once the department has received and successfully processed your payment, you will receive an email confirmation of your registration.

PLEASE include your registration number on the check when you mail it to DIA. This will enable DIA staff to match it up with this submitted form and process your registration more quickly.