Free 52233.pdf - Indiana

APPLICATION FOR LICENSE TO OPERATE AN ABORTION CLINIC
State Form 52233 (R2/6-06)

Indiana State Department of Health-Division of Acute Care (Pursuant to IC 16-21-2 and 410 IAC 26) Form Approved By State Board Of Accounts-2006

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. Abortion Clinic Location
Name of Abortion Clinic

Street Address

P.O. Box

City

County

Zip Code +4

Telephone Number ( )

Fax Number ( ) Abortion Clinic e-mail address:________________________________________________________

Internet Web Address:______________________________________________________________

B. Mailing Address (if different from abortion clinic 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)

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D. Services provided under this license:
Code items 1 and 2 as follows: 1. Provided directly by employee(s), 2. Provided by a contract service, 3. Both 1 and 2.

1. Ancillary Services:

2. Surgical Services:



Laboratory: CLIA Certificate # ______________________



Radiology



Counseling

Family Planning

Gynecology



Pharmacy



Other (List): ___________________________________

Other (List):____________________________________________

For item 3, indicate the total number of individuals (employees plus contractors) working in this clinic. This includes hourly, part-time, and full-time persons.

3. Staffing : Physicians:

Registered Nurses:

Licensed Social Workers:



Licensed Practical Nurses:


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

Other (List title and number): _______________________________

E. Number of Procedure Rooms Utilizing:

Local analgesia/anesthetic
F. Type of Entity: For Profit
Individual Partnership Corporation Limited Liability Company Sole Proprietorship



Moderate/Conscious Sedation

Non-Profit
Church Related Individual Partnership Corporation Limited Liability Company Other (specify) _____________________ _____________________________________ _____________________________________ _____________________________________

Other (specify) _____________________________ _____________________________________________ _____________________________________________ _____________________________________________

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

Name

Address/City/State/Zip

H. 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 Abortion Clinic (Clinic) 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 Abortion Clinic statues, IC 16-21-2-2.5 and IC 16-34, and the rules promulgated there under, 410 IAC 26 and will operate and maintain this clinic in accordance with those rules. I certify that the operational policies of the clinic 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 clinics in Indiana. Signature of the Medical Director: Printed Name and Title: Date of Signature: Signature of the Clinic 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 fee based upon the total number of first trimester procedures as reported to the Indiana State Department of Health (ISDH) on the Terminated Pregnancy Report (State Form 36526).

Total First Trimester Procedures in the Clinic Zero to 799 800 to 3,499 3,500 to 6,999 7,000 and above Indiana Hospital Council; 414 IAC 1-1-3

Check One

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

Enclose the following: 1. A completed Application for License to Operate an Abortion Clinic (this form); 2. Any supporting attachments; and 3. Payment made payable to "Indiana State Department of Health."

Mail to: INDIANA STATE DEPARTMENT OF HEALTH CASHIER'S OFFICE P. O. BOX 7236 INDIANAPOLIS, INDIANA 46207-7236

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