Free 52525.FH11 - Indiana

APPLICATION FOR LICENSURE AS A HOME MEDICAL EQUIPMENT SERVICE PROVIDER
State Form 52525 (3-06) Approved by State Board of Accounts, 2006

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FOR OFFICE USE ONLY
Date paid (month, day, year)

INDIANA BOARD OF PHARMACY PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2067 E-mail: [email protected]

Application fee License number

Receipt number Date of issue (month, day, year)

DO NOT WRITE ABOVE THIS LINE
DOCUMENTATION Attach copies of the following items to this application: 1. Medicare provider number ____________ (verification letter) 2. Medicaid provider number ____________ (verification letter) 3. Verification of each accreditation (if applicable) 4. Proof of insurance

BUSINESS INFORMATION
Legal name of business FEIN National Provider Identification (NPI) number (required after May 23, 2007) Medicare identification (NSC) number Medicaid number

Sole proprietorship Partnership

TYPE OF OWNERSHIP Limited liability corporation Corporation ALL TRADE / BUSINESS NAMES USED BY THE ENTITY

Other _______________________________ _______________________________

FACILITY INFORMATION
Address of principal facility (number and street, city, state and ZIP code) Telephone number Fax number County

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E-mail address Principal mailing address (number and street, city, state and ZIP code)

Website (if applicable) County

FACILITY LICENSES / CREDENTIALS (ex: Pharmacy, FDA, CDL, etc.)
Type Type Type Type Number Number Number Number Date of expiration (month, day, year) Date of expiration (month, day, year) Date of expiration (month, day, year) Date of expiration (month, day, year)

OFF-SITE STORAGE FACILITIES Number of off-site storage facilities or warehouses under the above listed ownership: ____________ List the address of each facility (attach additional sheets, if necessary).
Address of facility (number and street, city, state and ZIP code) Address of facility (number and street, city, state and ZIP code) Address of facility (number and street, city, state and ZIP code) Address of facility (number and street, city, state and ZIP code) County County County County

CONTACT PERSON (Individual completing application)
Name of contact person Telephone number Title E-mail address

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ACCREDITATION / CERTIFICATION (Required for all Medicare providers after 01/01/07))
Type Date of expiration (month, day, year)

SERVICES PROVIDED (Check all that apply)
Oxygen & oxygen delivery systems Ventilators Respiratory disease management devices Continuous positive airway pressure (CPAP) devices Electronic & computerized wheel chairs & seating systems Manual wheelchairs Apnea monitors Transcutaneous electrical nerve stimulators
If oxygen is checked above

Low air loss cutaneous pressure management devices Sequential compression devices Feeding pumps Home phototherapy devices Infusion delivery devices Distribution

Nebulizers Continuous Passive Motion (CPM) machines Defibrillators

SERVICESPatient lift devices PROVIDED (Check all that apply)
Other similar equipment as adopted by the Board: _______________________________________ _______________________________________ _______________________________________

Distribution of medical gasses to end users for human consumption Hospital beds & accessories
If yes, please provide FDA number.

Do you transfill oxygen?
If oxygen is checked above

Yes Yes

No
If yes, please provide DOT number.

Do you carry over 1,000 pounds?

No QUESTIONS

1. 2. 3. 4.

Has the applicant, or any of the applicants employees or associates ever been excluded from Medicare participation? Has the applicant, or any of the applicants employees or associates had a disciplinary action taken by the federal or state government of any license(s) held by any employee or associate? Has the applicant, or any of the applicants employees or associates ever been convicted of a felony? Is any action pending on any of the above? AFFIDAVIT

Yes Yes Yes Yes

No No No No

I do solemnly swear or affirm, under the penalties of perjury, that I am the person authorized to sign this application for licensure and that the statements made are true and correct in all respects.
Signature of contact person Title of contact person Date signed (month, day, year)