Free 50097.pdf - Indiana

APPLICATION FOR CONSTRUCTION PERMIT FOR AN ACUTE CARE FACILITY
State Form 50097 (R3/1-07)

DATE REC'D: RECEIPT NO:

INDIANA STATE DEPARTMENT OF HEALTH/ SANITARY ENGINEERING Approved by State Board of Accounts, 2007 INSTRUCTIONS:

1. Complete all sections, plus any additional documentation required, as described on the back and enclose with the plans. 2. Enclose a check or money order, payable to `Indiana State Department of Health', along with the plans submittal to: Indiana State Department of Health Attention: Cashier's Office P.O. Box 7236 Indianapolis, IN 46207-7236 3. Direct any questions regarding how to complete this application, via phone, to: (317) 233-7177

I. LICENSEE
Name: Address: City, State, ZIP: Phone No.: ( E-mail:

V. ATTACHMENTS (IF APPLICABLE)
VERIFY THE FOLLOWING ITEMS ARE INCLUDED IN THE SUBMITTAL: A. Plot Plans including Site Utilities........................ B. Life Safety Code Analysis (NFPA-101) certified by Architect / Engineer................................... N/A N/A N/A N/A Y Y Y Y

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C. Public Notification per IC16-21-2-11.5 ........... D. X-Ray Shielding Recommendations & Calculations...................................................

II. FACILITY
Project: Name: Address: City, State, ZIP:

VI. LICENSEE'S DESIGNATED AGENT
Name: Title: Address: City, State, ZIP: Phone No.: ( E-mail: Existing Existing New New

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III. PROJECT DETAILS
VERIFY THE FOLLOWING INFORMATION: A. Water Supply............................... B. Sewage Disposal..........................

VII. ENGINEER / ARCHITECT
Name: Firm: Address: City, State, ZIP: Phone No.: ( E-mail: License No.:

C. License of the Facility: Hospital (Inpatient/Outpatient) Ambulatory Outpatient Surgery Center (AOSC) D. Facility Type: Hospital (Inpatient/Outpatient) Ambulatory Outpatient Surgery Center (AOSC) Primary Care Outpatient Facility (if `YES', answer below)
Max. number of employees working at any one time:

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Excluded Rehabilitation / Psychiatric Unit (if `YES', answer below)
Fiscal Year-End Date (MM/DD/YY):

E. Conduct Invasive Procedures / Applications?....... F. Estimated Cost of Construction....$

N

Y Signature:

No anticipated additional cost of construction; existing structure

G. Estimated Start of Construction...... H. Estimated Occupancy / Opening.....

VIII. SIGNATURE
I, THE UNDERSIGNED, CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF, THE INFORMATION CONTAINED ON THIS APPLICATION IS COMPLETE AND ACCURATE.

IV. ATTACHMENTS
VERIFY THE FOLLOWING ITEMS ARE INCLUDED IN THE SUBMITTAL: A. Plans and/or Specifications Certified by an Architect or Engineer................................................................ B. Payment ­ Fees Required per 410 IAC 6-12-17............. C. Scope of the Proposed Project....................................

Name (printed): Title: Y Y Y Signature: Date Signed:

INSTRUCTIONS FOR COMPLETION OF CONSTRUCTION PERMIT FOR AN ACUTE CARE FACILITY
No. SECTION I. II. III. LICENSEE FACILITY PROJECT DETAILS DESCRIPTION
Specify the name and address of company, firm, municipality, authority, etc.. Specify the name and address.

A. B. C. D.

Indicate whether the water supply is `new' or `existing'. Indicate whether the sewage disposal is `new' or `existing'. Indicate the licensee's type of license. Indicate the facility type.
NOTE: FOR `PRIMARY CARE OUTPATIENT FACILITY' OR `EXCLUDED REHABILITATION / PSYCIATRIC UNIT', ANSWER ADDITIONAL QUESTION FOR EACH.

E. Specify whether `invasive procedures or applications' are to be performed at the facility. F. Indicate the estimated cost of construction, less equipment installation and consulting fees.
NOTE: IF AN EXISTING STRUCTURE SEEKING LICENSURE WITHOUT CONSTRUCTION, LEAVE BLANK AND `CHECK' BOX.

G. Provide an estimated date (MM/DD/YY) that construction will start. H. Provide an estimated date (MM/DD/YY) of occupancy. IV. ATTACHMENTS A. Detailed architectural plans and specifications including site utilities, mechanical and
electrical prepared by an IN registered architect or engineer.

B. Fees Required per Rule 410 IAC 6-12-17, payable via check or money order
Ambulatory Outpatient Surgery Center (AOSC).............................................. ...$450 New Hospital or Hospital Addition.................................................................... $550 Remodeling of an Existing Hospital................................................................... ...$300
NOTE: IF A FACILITY IS NOT CURRENTLY UNDER LICENSURE, THEN THE FACILITY IS CONSIDERED `NEW' CONSTRUCTION. THEREFORE, `SHELL SPACE' IS INCLUDED INTO THIS CATEGORY.

C. Provide a complete detailed description regarding the use of the proposed licensed facility
and its previous usage, if applicable.

V.

ATTACHMENTS (IF APPLICABLE)

A. Provide scaled plot plan(s) that specify property lines, structures, roads and site utilities. B. Hospitals and AOSC's shall comply with Life Safety Code (NFPA 101, 2000 edition) and
must be certified by an IN registered architect or engineer. Attach analysis.

C. Public Notification Required per IC16-21-2-11.5
If the total construction costs, less equipment and consultants fees, exceeds $3,000,000 for an AOSC or $10,000,000 for a Hospital, then the following shall be provided:
C-1. A copy of each of the (2) published public notices, including the dates published, the name of the publication(s) and in what city(s) or town(s); and C-2. A letter from the owner / owner's representative to verify: (A) public hearings were held on the date and times listed per response to C-1; and (B) an agenda that shows the following was presented to the public: (i) a description of; (ii) an estimate of the cost of; and (iii) a description of the health care services that will be provided by the Hospital / AOSC as a result of the construction project.

D. X-ray shielding recommendations and calculations, prepared by an IN registered physicist. VI. LICENSEE'S DESIGNATED AGENT ENGINEER / ARCHITECT SIGNATURE
Provide the name, title, address, phone number and e-mail of an individual, who is designated to act for the Licensee, and who is familiar with the project and can furnish additional information, as required. Provide the name, title, firm, address, phone number and e-mail of the engineer or architect, registered in State of Indiana, who certified and sealed the construction plans and specifications. License number and a signature (including date signed) must be provided. An application submitted by a corporation must be signed by a principal executive officer of at least Vice President level or his duly authorized representative, if such a representative is responsible for the overall operation at the facility from which the construction described in the form will originate. In the case of a partnership or a sole proprietorship, the application must be signed by a general partner or the proprietor, respectively.

VII.

VIII.