Free 44885.pdf - Indiana

APPLICATION FOR LICENSE TO OPERATE A HOSPITAL
State Form 44885 (R5/6-04) Indiana State Department of Health-Division of Acute Care (Pursuant to IC 16-21-2 and 410 IAC 15-1.3-1 ) 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: Submit a dated and signed copy of the
bill of sale, lease or other document of transfer.

SECTION II - IDENTIFYING INFORMATION A. Hospital Location (facility location)
Name of Hospital

Street Address

P.O. Box

City

County

Zip Code +4

Telephone Number ( )

Fax Number ( ) P.O. Box

B. Mailing Address (if different from hospital location)
Street Address

City

County

Zip Code +4

C. Ownership Information
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. Provider Numbers
Medicare Provider Number: Medicaid Provider Number:

1

E. Additional Services and/or Off-site Practice Locations Operated Under Hospital License: If not applicable, leave blank. Do not list on-site skilled or distinct part units unless located off-site. (use additional sheet if necessary)

Type of Service

Name

Address

Provider Number if different from Hospital

Blood Center Hospice Home Health Other Off-Site Locations List below:

2

F. Long Term Care Unit: Does the hospital have a long term care unit? ____Yes Are the beds Medicare certified? _____Yes _____No

_____No

If yes: Number of Beds _______

If yes, Medicare certification number: __________________________ Is the long term care unit also licensed by the Indiana State Department of Health Division of Long Term Care? _____Yes G. Beds: _____No

Total Number of setup and staffed beds for inpatients in the hospital (exclude pediatric visitors, newborn nursery cribs, maternity labor and delivery beds) as of the date of this application: _______ Does this facility have swing beds?
H. Hospital within a Hospital Status: Is this a host hospital? _____Yes _____No _____No

_____Yes

_____No

Is this a tenant hospital? _____Yes

I. Type of Control: (Check all that apply) For Profit Non-Profit Government

· · · · ·

Sole Proprietorship Partnership Corporation Limited Liability Company Other: (specify below)

· · · · · ·

Church Related Sole Proprietorship Partnership Corporation Limited Liability Company Other (specify below):

· · · · · ·

State County City City/County Federal Other (specify below):

_____________________________________________ _____________________________________________

_____________________________________ _____________________________________

________________________________ ________________________________

J. Corporate Officers (complete if the business entity is incorporated)

Position President/Chairperson/CEO Vice-President/Vice-Chairperson/COO Treasurer/CFO Secretary

Name

Address/City/State/Zip

K. Change in Ownership If this application is for a change in ownership (required if the change in ownership is fifty percent (50%) or greater), complete the following. Otherwise, leave blank. (The mere sale of shares of an owning corporation [or for corporations controlled by a `member' or ` members' which can be individuals, partnerships, or other corporations] does not constitute a change of ownership)

· · ·

Asset Purchase Agreement Merger Termination of Lease

· · ·

Assignment of Interest New Partnership Transfer of Asset Agreement

· · ·

Lease Sale Other ______________________

3

Change of Ownership Continued List names and addresses of individuals or organizations having direct or indirect ownership or controlling interest of five percent (5%) or more 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 make application for a license to operate a hospital in the State of Indiana pursuant to hospital statute, IC 16-21, and the rules promulgated there under at 410 IAC 15. I certify that the operational policies of the hospital 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 true and accurate and in compliance with regulations, laws, and rules governing the licensing of hospitals in Indiana.

Signature of Chief Executive Officer or designee: Printed Name and Title: Date of Signature: Signature of Governing Board Chairperson/President or designee: Printed Name and Title: Date of Signature: Signature of Chief of Medical Staff or designee: Printed Name and Title: Date of Signature:

License Fee
Select the appropriate license fee below and return the application, any attachments, and license fee made payable to: INDIANA STATE DEPARTMENT OF HEALTH ATTENTION: CASHIER 2ND FLOOR P. O. Box 7236 INDIANAPOLIS, INDIANA 46207-7236 Total Operating Expenses are found on the most recently filed Hospital Fiscal Report, State Form 49520 as required by IC 16-21-6-3. Check Total Operating Expenses Fee One Zero to $49,999,999.00 $1,000.00 $50,000,000.00 to $99,999,999.00 $2,000.00 $100,000,000.00 to $199,999,999.00 $3,000.00 $200,000,000.00 to $299,999,999.00 $4,000.00 $300,000,000.00 and above $5,000.00 Indiana Hospital Council; 414 IAC 1-1

4