Free 9340-R5-6-04-App-Lic Opr.Ambulatory Outpatient Surgical Ct... - Indiana

APPLICATION FOR LICENSE TO OPERATE AN AMBULATORY OUTPATIENT SURGICAL CENTER
State Form 9340 (R5/6-04) Indiana State Department of Health-Division of Acute Care (Pursuant to IC 16-21-2 and 410 IAC 15-2.3-1 ) Form Approved By State Board Of Accounts-2004

Division of Acute Care Use Only Date Received__________________ Date Approved__________________ Date Rejected __________________

Please Type or Print Legibly SECTION I - TYPE OF APPLICATION Application (check appropriate item)

· New Facility

· Renewal

· Change of Ownership (Anticipated date of Sale/Purchase/Lease)__________________
Submit a dated and signed copy of the bill of sale, lease or other document of transfer

SECTION II - IDENTIFYING INFORMATION A. Surgical Center Location
Name of Surgical Center

Street Address

P.O. Box

City

County

Zip Code +4

Telephone Number ( )

Fax Number ( )

Hours Procedures are Performed (if no procedures performed indicate "closed"): Monday Tuesday Wednesday Thursday Friday Saturday Sunday

B. Mailing Address (if different from surgical center location)
Street Address P.O. Box

City

County

Zip Code +4

C. Licensee/Ownership Information
Licensee: The applicant entity as registered with the secretary of state

Street Address

P.O. Box

City

State

Zip Code+4

Telephone Number ( )

Fax Number ( )

EIN Number

Fiscal Year End Date (mm/dd)

D. Supplier Numbers
Medicare Supplier Nu mber: 15C____________________ Medicaid Supplier Number (Related Supplier Number):_________________________

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E. Services provided under this license:
Coded as follows: 1. Provided directly by employee, 2. Provided by a contract service, 3. Both 1 and 2.

Ancillary Services:

Laboratory

Radiology

EKG

Pharmacy

Surgical Services:

Cardiovascular Ophthalmology Urology

Foot Oral

General Orthopedic

Neurological Otolaryngology Other

Obstetrics/Gynecology Plastic Thoracic

Gastroenterology

F. Number of Operating Rooms (as classified in the AIA, 2001 guidelines): Class A Class B Class C Endoscopy

G. Off-site centers: Are there off-site facilities under this license? _____ Yes If yes please complete the following information: Name _______No

Address/City./State/Zip

Telephone Number

H. Accreditation:
Does this center have accreditation that is "deemed" to meet CMS Conditions of Coverage? If accredited, please complete the following: Name Effective Date of Accreditation _____Yes _____No Expiration Date of Accreditation

I. Type of Entity: For Profit Non-Profit Government

· · · · · ·

Individual Partnership Corporation Limited Liability Company Sole Proprietorship Other (specify) _____________________________

· · · · ·

Church Related Individual Partnership

·

· · · ·

·
County City

State

Corporation

Limited Liability Company Other (specify) _____________________

· ·
Federal

City/County Hospital District

_____________________________________________ _____________________________________________ _____________________________________________

_____________________________________ _____________________________________ _____________________________________

Other (specify) ________________

________________________________ ________________________________

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J. Officers (if the business entity is incorporated) Position President/Chairperson/CEO Vice-President/Vice-Chairperson/COO Treasurer/CFO Secretary

Name

Address/City/State/Zip

K. Ownership and/or Change in Ownership: List names and addresses of individuals or organizations having direct or indirect ownership or controlling interest of five percent (5%) in the applicant entity. Indirect ownership interest is 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/City/State/Zip EIN Number

CERTIFICATION OF APPLICATION The undersigned hereby makes application for a license to operate an Ambulatory Outpatient Surgical Center (Center) in the State of Indiana, and in support of this application, represents and shows that the owner(s) and operator(s) are of reputable and reasonable character, are able to comply with the Ambulatory Outpatient Surgical Center statues, IC 16-21, and the rules promulgated thereunder, 410 IAC 15-2.1 and will operate and maintain this center in accordance with those rules. I certify that the operational policies of the center will not provide for discrimination based upon race, color, creed, or national origin. I swear and affirm under the penalty of perjury that all statements made in this application and any attachments thereto are correct and complete and that I will comply with all regulations, laws, and rules governing the licensing of centers in Indiana. Signature of Chief Executive Officer/Owner: Printed Name and Title: Date of Signature: Signature of the Facility Administrator: Printed Name and Title: Date of Signature:

See the following page for instructions regarding licensure fees and submission of this application

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License Fee

Select the appropriate license fee below and return the application, any attachments, and license fee to: INDIANA STATE DEPARTMENT OF HEALTH CASHIER'S OFFICE P. O. BOX 7236 INDIANAPOLIS, INDIANA 46207-7236

Total Annual Procedures are found on the fourth quarter report entitled "Quarterly Utilization Review Report/Ambulatory Surgery Center (State form 49933)," item III, line "Since the beginning of the year", right hand box.

Check One

Total Annual Procedures

Fee $500.00 $1,000.00 $2,000.00 $3,000.00

Zero to 799 800 to 3,499 3,500 to 6,999 7,000 and above Indiana Hospital Council; 414 IAC 1-2

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