Free 08200.PDF - Indiana

APPLICATION FOR LICENSE TO OPERATE A HEALTH FACLITY
(Pursuant to IC 16-28 and 410 IAC 16.2)
State Form 8200 (R3/08-00) Indiana State Department of Health-Division of Long Term Care

DIVISION OF LONG TERM CARE Date Received________________________________ Date Approved________________________________ Approved by__________________________________
Please Print or Type SECTION I - TYPE OF APPLICATON Application (check appropriate item)

· Change of Ownership (Anticipated date of Sale/Purchase/Lease)__________________ · New Facility ·
SECTION II - IDENTIFYING INFORMATION A. Practice Location (facility)
Name of Facility Street Address City Telephone Number ( ) Fax Number ( ) County Facility's Cost Reporting Year From (mm/dd):

Other___________________

P.O. Box: Zip Code +4

To (mm/dd):

B. Licensee/Ownership Information
Licensee (Operator(s) of the facility) The licensee and the applicant entity as described in Item IV-A of this application should be the same. Street Address City Telephone Number ( ) Fax Number ( ) State EIN Number P.O. Box Zip Code+4 Fiscal Year End Date (mm/dd)

C. Building Information 1. Status of building to be used (check appropriate item)

· Proposed New Construction ·
2. ________________________

Alteration of Existing Building

·

Existing Licensed Health Facility

·

Other__________________________

Type of Construction (materials) (if new, as certified by architect or engineer registered in the state of Indiana) ________________________ ________________________ ________________________

D. Type of Services to be Provided 1. Level of Care

Number of Beds in Each Category (to be licensed)

2.

Certification Designation

Number of Beds in Each Category (to be licensed)

· Residential · Comprehensive (Certified) · Comprehensive (Non-certified) · Children's Facility · Developmentally Disabled
Total Number of Licensed Beds

____________

· SNF (Title 18 ­ Medicare) · SNF/NF (Title 18 ­ Medicare/Title 19 ­ Medicaid) · NF (Title 19 ­ Medicaid) · ICF/MR

____________

____________

____________

____________

____________

____________

____________

____________

____________

Total Certified Beds

____________

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SECTION III ­ STAFFING A. Administrator
Name (enter full name) Indiana License Number (please include a copy of license with application) 1. List post secondary education and health related experience ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ 2. On a separate sheet, list the facilities in Indiana, or any other state, in which the Administrator has been previously employed, including the dates of employment and reason for leaving. Identify on this list any of these facilities which were operating with less than a full license at the time the Administrator was employed. Has the administrator ever been convicted of any criminal offense related to a dependent population? (If yes, state on a separate sheet the facts of each case completely and concisely) Has the administrator's license ever lapsed, been suspended or revoked? Yes (If yes, state on a separate sheet the facts of each case completely and concisely) Date of Birth Date employed in this position

3.

·

Yes

·

No

4.

·

·

No

5.

Is the administrator presently in good health and physically able to fully carry out all of the duties in the operation of this health facility?

·

Yes

·

No

(If no, explain on a separate sheet)

B. Director of Nursing
Name (enter full name) Indiana License Number (please include a copy of license with application) Education (Name of School of Nursing) School Degree Other College Education Qualifications or Experience Year Graduated Date of birth Date employed in this position

1. Has the Director of Nursing ever been convicted of any criminal offense related to a dependent population? (If yes, state on a separate sheet the facts of each case completely and concisely) 2. Has the Director of Nurse's License ever lapsed, or ever been suspended or revoked? (If yes, state on a separate sheet the facts of each case completely and concisely)

·

Yes

·

No

·

Yes

·

No

SECTON IV - DISCLOSURE OF OWNERSHIP AND CONTROLLING INTEREST STATEMENT (In compliance with the Indiana Health Facilities Rules (410 IAC 16.2) A. Applicant Entity
Name of Applicant Entity (operator(s) of the facility) D/B/A ( Name of Facility)

B. Ownership Information List names and addresses of individuals or organizations having direct or indirect ownership interest of five percent (5%) or more in the applicant entity. Indirect ownership interest is interest in an entity that has an ownership interest in the applicant entity. Ownership in any entity higher in a pyramid than the applicant constitutes indirect ownership. (use additional sheet if necessary)
Name Business Address EIN Number

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C. Type of Change of Ownership

· · · · · · ·

Assignment of Interest Sale

· ·

Lease Sublease

· ·

Merger Termination of Lease

· · · · · · · · ·

New Partnership Other________________

D. Type of Entity For Profit
Individual * Partnership ** Corporation *** Limited Liability Company Other (specify) _____________________________

NonProfit

Government
State County City City/County Hospital District Federal Other (specify) ________________

_____________________________________________ _____________________________________________

· · · · · ·

Church Related Individual * Partnership ** Corporation *** Limited Liability Company Other (specify) _____________________

_____________________________________

*If a Limited Partnership, submit a copy of the "Application For Registration" and "Certificate of Registration" signed by the Indiana Secretary of State. **If a Corporation, submit a copy of the "Articles of Incorporation" and "Certificate of Incorporation" signed by the Indiana Secretary of State. If a foreign Corporation, submit a copy of the "Certificate to do Business in the State of Indiana" signed by the Indiana Secretary of State. ***If a Limited Liability Company, submit a copy of the "Articles of Organization" and the "Certificate of Organization" signed by the Indiana Secretary of State.

SECTION V - DISCLOSURE OF APPLICANT ENTITY A. Officers/Directors/Members/Partners/Managers
1. List all individuals (persons) associated with the applicant entity and indicate the individual's title (i.e. officer, director, member, partner, etc). If the applicant is a partnership, list the name and title of each partner or the name and title of all individuals associated with each entity that forms the partnership. If the applicant is a Limited Liability Company, list the name and title for all individuals associated with each member entity that forms the Limited Liability Company. (use additional sheet if necessary) Name Title Business Address Telephone Number

2. Are any individuals (persons) associated with the applicant entity (as listed in Sections IV.B and V.A.1) also associated with any other entity operating health facilities in Indiana or any other states?

·

Yes

·

No (use additional sheet if necessary) Address

If "yes," list names and addresses of facilities owned by each individual. Facility Name

City, County, State, Zip Code

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3.

Is the licensee (applicant) a lease entity?

· Yes · No

If yes, explain_________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Please submit a copy of the lease showing an effective date. If this is a sublease or assignment of interest of a lease, submit a copy of all Leases affected by this transaction. 4. Is the applicant a subsidiary of another entity or corporation or does the applicant have subsidiaries under its control? (If yes, list each entity (affiliated entity) on a separate sheet and explain the relationship)

·

Yes

· No

B. Licensure/Operating History Are any of the individuals (as listed in Sections IV.B. and V.A.1.), associated with or have they been associated with, any other entity that is operating, or has operated, health facilities in Indiana or any other state, that:
1. Has/had a record of operation of less than a full license (i.e. three month probationary, provisional, etc)

·

Yes

·

No

(If "Yes", provide name of facility, state, date(s), restrictions and type)

2. Had a facility's license revoked, suspended or denied.

·

Yes

·

No

(If "Yes", provide name of facility, state, type of actions and date(s))

3. Was the subject of decertification, termination, or had a finding of patient abuse, mistreatment or neglect.

·

Yes

·

No

(If "Yes", provide name of facility, state, date, type of action, results of action)

4. Had a survey finding of Substandard Quality of Care or Immediate Jeopardy deficiency reports, including the current or final resolution of the matter)

·

Yes

·

No

(If "Yes", provide all correspondence and

5. Filed for bankruptcy, reorganization or receivership. Yes No (If "Yes", include all relevant documentation and provide a detailed summary of the events and circumstances. Include state, dates and names of facilities) NOTE: If any of the answers above are "Yes", list each facility on a separate sheet of paper and explain the facts clearly and concisely.

·

·

SECTION VI - CERTIFICATION OF APPLICATION I hereby certify that the operational policies of the health facility will not provide for discrimination based upon race, color. creed or national origin. I swear or affirm that all statements made in this application and any attachments thereto are correct to the best of my knowledge and that the applicant entity will comply with all laws, rules and regulations governing the licensing of health facilities in Indiana. Applicant's signature, as indicated in V-A of this application, or signature of applicant's agent should appear below.
IF SIGNED BY ANY INDIVIDUAL (EG., THE ADMINISTRATOR) OTHER THAN INDICATED IN SECTION V.A.1. OF THIS APPLICATION, AN AFFIDAVIT MUST BE SUBMITTED WITH THE APPLICATION AFFIRMING THAT SAID PERSON HAS BEEN GIVEN THE POWER TO BIND THE APPLICANT/LICENSEE. Title Name of Authorized Representative (Typed) Signature Date

STATE OF ______________________________

COUNTY OF ______________________________________

Subscribed and sworn to before me, a Notary Public, for _______________________County, State of_________________________, this ______________day of ________________20________

(SEAL)

(Signature)_______________________________________________________ ____________________________________________, Notary Public
(Type or Print Name)

My Commission expires_____________________________________________

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