Healthcare facility licensing

Health care facilities carry out prescribed medical and dental procedures. They might also offer overnight patient stays before or after medical treatment. The operator of a health care facility must hold a Health Care Facility Activity Licence.

A health care facility is a premises upon which prescribed medical or dental procedures are carried out and/or a premises where overnight patient stays are provided.

The operator of a health care facility must hold a Health Care Facility Activity Licence.

Licences are issued under the ACT Health Care Facilities Code of Practice 2001.

Prescribed medical and dental procedures are defined by the Code as activities carried out for medical or cosmetic reasons by a health care professional, involving:

  • the administration of general, spinal, epidural or major regional block anaesthetic or intravenous sedative for the purpose of performing an elective procedure, not including mandibular blocks;
  • endoscopy;
  • dialysis, haemofiltration or haemoperfusion;
  • prolonged intravenous infusion of a single cytotoxic agent or sequential intravenous infusion of more than one cytotoxic agent; or
  • cardiac catheterisation.

ACT Health Directorate is reviewing the regulation of health care facilities in the ACT. The discussion paper Update to the Licensing and Regulation of Health Care Facilities will be released for public consultation submissions from Monday 10 August 2020 to Friday 18 September 2020. For more information about the consultation visit the Health Care Facilities Consultation page.

Licence applications

The Health Protection Service encourages applicants to discuss their fit-out plans and proposed procedures with us. Please call 02 5124 9700 during business hours or email hps@act.gov.au.

An application for a Health Care Facility Activity Licence can be submitted online or in hard copy. Applications must be accompanied by the fee and fit-out plans.

Please send application form and plans:

  • online;
  • by email hps@act.gov.au;
  • by post to Health Protection Service, Locked Bag 5005, Weston Creek, ACT 2611; or
  • in person at Health Protection Service, 25 Mulley Street, Holder (during business hours, 9:00 am to 4:30 pm weekdays).

If you need to update or change the details on your licence, please apply online for a Health Care Facility Licence Variation.

If ownership of the facility changes, please submit a Transfer of Ownership form.

Forms:

Current licence fees

Please see the table below for licence fees.

Type of Facility Annual Fee
Accredited facility (<200 beds) $664
Accredited facility (>200 beds) $1327
Non-accredited facility $993
Dental practitioner $265

Please note: there is a $81 fee for transfer of a licence.

Accreditation

ACT Health follows the National Safety and Quality Health Service Standards (NSQHS). 

New facility operators should use an accreditation agency from the list approved by the Australian Commission on Safety and Quality in Healthcare.

If you have any questions, please contact the Health Protection Service on 02 5124 9700.

Structure of Facilities

Please see the following links for compliance with relevant health care facility structure standards.

For more information on building guidelines for the ACT, please see the Environment, Planning and Sustainable Development Directorate website:

Information Management

All general records maintained by health care facilities must be stored in accordance with Australian Standards. This includes storage of accounts, insurance documents and correspondence.

The procedure for storing medical, or health records is set under Part 5 of the ACT Health Care Facilities Code of Practice 2001.

Food Safety

If you provide food to your patients, you must register as a food business. You must also meet the requirements of the Food Act 2001, the Food Regulation 2002 and the Australia New Zealand Standards Code. This may include the option of a Food Safety program for providing food to vulnerable groups.

You can discuss your food safety obligations with our public health officers on 02 5124 9700 or hps@act.gov.au.

Nutritional Assessment

Health care facility licensees must ensure all food provided is consistent with the Australian Dietary Guidelines.

Laundering

Health care facility licensees must ensure all linen used is cleaned in accordance with Australian Standards. You can purchase Standards from SAI Global.

Clinical Waste Management

Clinical waste arises from the treatment and care of patients. Clinical waste includes hypodermic needles, scalpels, tissue and fluid specimens, pharmaceuticals and materials that have been in contact with these substances.

Health care facility licensees must comply with the Clinical Waste Act 1990 and the Clinical Waste Manual 1991. These documents detail the requirements about the storage, treatment, transportation and disposal of clinical waste. This includes the engagement of an approved entity for the removal of clinical waste from a facility.

ACT legislation

ACT Health encourages you to familiarise yourself with relevant ACT legislation including:

  • Public Health Act 1997
  • Children and Young People Act 2008
  • Clinical Waste Act 1990
  • Food Act 2001
  • Health Records (Privacy and Access) Act 1997
  • Medical Treatment (Health Directions) Act 2006
  • Medicines, Poisons and Therapeutic Goods Act 2008
  • Radiation Protection Act 2006
  • Work Health and Safety Act 2011

You can find these Acts and other legislation on the ACT Legislation Register.

Contact the Health Protection Service

Our office hours are 9:00 am to 4:30 pm on weekdays.

You can contact us on 02 5124 9700 or hps@act.gov.au. The fax number is 02 5124 5554.

Health Protection Service is located at 25 Mulley Street, Holder ACT 2611.

The postal address is Locked Bag 5005, Weston Creek ACT 2611.

Page last updated on: 6 Aug 2020