Free APPLICATION FOR LICENSE - Indiana

APPLICATION FOR LICENSE TO OPERATE A PERSONAL SERVICES AGENCY
State Form 53391 (R/4-08) Approved by State Board of Accounts, 2008

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Indiana State Department of Health-Division of Acute Care
(Pursuant to IC 16-27-4)

Division of Acute Care Use Only Date Received__________________
(month, day, year)

Date Approved__________________
(month, day, year)

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All questions on this application must be answered completely in printed or typed script. Supporting documentation must be attached. AN INCOMPLETE OR ILLEGIBLE APPLICATION WILL BE RETURNED WITHOUT BEING PROCESSED. License and/or approval renewal must be obtained annually. This application and the license, and/or approval which may be issued as a result, are neither assignable nor transferable. A non-refundable application fee in the amount of $250.00 must accompany this application. No license and/or approval shall be issued without receipt of this fee.

Please Type or Print Legibly SECTION I - TYPE OF APPLICATON Application ( type of application is required to be checked )
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 New Agency

SECTION II - IDENTIFYING INFORMATION A. Personal Services Agency Parent Location (name of agency - d/b/a of corporation, limited liability company, partnership, etc)
If the "doing business as" name (d/b/a) is different from the name of the direct owner i.e. corporation, limited liability company, partnership, etc submit a "Certificate of Assumed Business Name" document from the Indiana Secretary of State (SOS) that list the name of direct owner's corporation, etc and the "doing business as" name (d/b/a). You must register the direct owner's corporation name etc and the d/b/a name with the SOS. Name of agency (the name should be listed in this section as it appears on the document from the SOS) Street address (number and street) P.O. Box

City Telephone number Fax number

County Agency's office hours (i.e. 8:00 a.m. ­ 4:00 p.m.) Monday Tuesday Wednesday Thursday

ZIP Code +4

Friday

Saturday

Sunday

( ) E-mail address

(

) Web address

B. Mailing Address (if different from practice location)
Street address (number and street) City State P.O. Box ZIP Code +4

C. Licensee/Ownership Information
The direct owner (i.e. the name of the corporation, limited liability company, partnership, etc) must be registered with the Indiana Secretary of State (SOS) as Articles of Incorporation, Certificate of Incorporation or Certificate of Organization, Certificate of Assumed Business Name, etc. Submit applicable document from the SOS and a document from the Internal Revenue Services (IRS) that reflects the corporation, name, etc, D/B/A name if applicable and EIN Number. The IRS document must be from the IRS and not a document requesting an EIN number. Licensee/Owner of the agency (the name should be listed in this section as it appears on the document from the SOS) Street address (number and street) City Telephone number ( ) EIN Number (submit document from IRS to validate) State Fax number ( ) Fiscal year end date (mm/dd) P.O. Box ZIP Code+4

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D. Branch offices operated under this license (as defined IC 16-27-4-6 (b)) Each branch office operated under the license of the parent personal services agency as listed in Section II.A. of this application must be: 1. at a location or site from which the personal services agency provides services; 2. owned and controlled by the parent personal services agency; and 3. located within a radius of one hundred twenty (120) miles of the parent personal services agency If the provider has an additional branch that is licensed under the parent, list the branch below and submit a copy of a map that reflects the mileage from the parent to the branch location.
Name Address (street address/city/zip) County Telephone Number

SECTION III ­ STAFFING Submit a national criminal history background check from the Indiana State Police Central Repository on the staff below A. Manager (as defined in IC 16-27-4-9 and IC 16-27-4-17 (b) (3)) - complete sections with manager's home address
Last Name Street address (number and street) County State First Name City ZIP Code +4 Initial

B. Alternate Manager (as defined in IC 16-27-4-9 and IC 16-27-4-17 (b) (3) - ) complete sections with alternate manager's home address
Last Name Street address (number and street) County State First Name City ZIP Code +4 Initial

SECTON IV - OWNERSHIP A. Ownership and Controlling Interest (officers/directors/managing agents/managing employees of the personal services agency) 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. (as defined in IC 16-27-4-17 (b))
Name Business Address (street address/city/state/zip) EIN Number

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B. Type of Ownership (applicable for change of ownership only ­ DO NOT complete if initial application)

Asset Purchase Agreement Merger Termination of Lease

Assignment of Interest New Partnership Transfer of Asset Agreement

Lease Sale Other ______________________

Submit a bill of sale or comparable document, which includes corporation/owner(s) name(s) and buyer/seller signature(s) and effective date of transaction with the application.

C. Type of Entity For Profit
Individual Partnership Corporation Limited Liability Company Sole Proprietorship Other (specify) _____________________________

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

Government
State County City City/County Federal Other (specify) _________________ ________________________________

_____________________________________________

_____________________________________

D. Directors/Officers/ Partners/Managing Agents/Managing Employees (Direct owners)
List all individuals (persons) associated with the applicant entity and indicate the individual's title (i.e. officer, director, member, partner, president, vice president, secretary, treasurer, CEO, CFO, 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. (as defined in IC 16-27-4-

17 (b))
Name Title-Position (list if owner (i.e. president/owner) Business Address (street address/city/state/zip)

SECTION V - CERTIFICATION OF APPLICATION
The undersigned hereby makes application for a license to operate a Personal Services Agency (agency) in the State of Indiana, and in support of this application, represents and shows that the owners and operators are of reputable and responsible character, are able to comply with the personal services agency laws, IC 16-27-4, and will operate and maintain this agency in accordance with those requirements. I hereby certify that the operational policies of the agency will not provide for discrimination based upon race, color, creed or national origin. I swear or 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 agencies in Indiana. Signature of manager and the president/chairperson/CEO as indicated in Section IIII.A. and IV.D. of this application. Signature of personal services agency manager as indicated in Section III.A. on this application.
President/Chairperson/CEO) (typed)

Signature of President/Chairperson/CEO)

Date (month/day/year)

Personal Services Agency Manager (typed)

Signature of Personal Services Agency Manager

Date (month/day/year)

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SECTION VI - POLICES AND DOCUMENTATION Submit the policies and documentation required as defined in Personal Services Agencies IC 16-27-4 and the applicable documentation from the Indiana Secretary of State and the Internal Revenue Services with the initial application. Do not intermingle Family Social Services Administration polices and documentation with the Indiana State Department of Health polices and documentation for personal services agency. Do not send a handbook as polices and documentation and/or cut and paste IC 16-27-4 as polices and documentation. All documentation must be received and approved prior to issuance of a license to operate a personal services agency.

Policies and documentation to be submitted with initial licensure application: Submit the following policies and forms: 1. 2. Unstable health conditions (IC 16-27-4-8) a. Submit policy Client satisfaction review (IC 16-27-4-11) a. Submit policy b. Submit satisfaction review form Complaint investigations (IC 16-27-4-13) a. Submit policy b. Submit complaint investigation form Tuberculosis test (control of communicable disease) (IC 16-27-4-15) a. Submit policy ­ Complete a tuberculosis test in the same manner as required by the state department for license home health agency employees - refer to the 410 IAC 17-2-1 Compliance documentation (IC 27-4-18) a. Submit policy

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5.

Submit the following documentation and forms: 1. 2. Copy of the Manager's responsibilities for day to day operations (IC 16-27-4-9(a) a. Submit manager's responsibilities Content of the Evaluation and Training conducted for competency requirements (IC 16-27-4-16) a. Submit documentation on how the provider will evaluate and re-evaluate employee on services provided to client by provider, who will conduct training and to ensure signature and date of the person conducting the training and the employee receiving the training, ensure that the person is competent to perform the tasks without direct supervision and the evaluations/training must be documented for each employee who performs personal services. b. Submit a copy of the training and evaluation (i.e. test) Copy of the agency's Service Plan (IC 27-4-10) a. Submit documentation b. Submit service plan form Copy of the agency's Client Rights Statement (IC 27-4-12) a. Submit documentation

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4.

Secretary of State (SOS) documentation: The applicant must register with the office of the Secretary of State to conduct business in Indiana. If the "doing business as" name (D/B/A) is different from the corporation, limited liability company, partnership, etc name you are required to submit a "Certificate of Assumed Business" name document from the (SOS). Submit applicable document with initial application. (a) If a limited Partnership, submit a copy of the "Application for Registration " and "Certificate of Registration" signed by the Indiana Secretary of State. (b) If a Corporation, submit a copy of the "Articles of Incorporation" and Certificate of Incorporation" signed by the Indiana Secretary of State. (c) If applicant is an out of state corporation (foreign corporation), submit a copy of the "Certificate of Authority" to do business in the State of Indiana" signed by the Indiana Secretary of State. (d) 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. (e) If the "doing business as" (d/b/a) name is different from the corporation's (direct owner) name submit "Certificate of Assumed Business Name" or "Articles of Incorporation" that list the owner and d/b/a name signed by the Indiana Secretary of State. Internal Revenue Services (IRS) documentation: The applicable must submit a SS-4 or comparable document from the Internal Revenue Service (IRS) that reflects direct owner's corporation, limited liability company, partnership, etc name, d/b/a if applicable and EIN number. The document must be from the IRS sent to the provider not a form/document the provider completed and sent to the IRS.

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SECTION VII - ADDITIONAL INFORMATION CHANGES AFTER INITIAL LICENSURE If the agency has future changes notify the Department as follows: · Submit the changes listed below in writing on provider letterhead o Manager (submit criminal history check from the Indiana State Police) o Address o Telephone/fax numbers o Branches - add/remove (complete address, county, map with mileage from parent to branch) o Officers (name, title, complete address Submit the change listed below in writing on provider letterhead and applicable document from the Secretary of State o Name change Submit a change of ownership application for a change in ownership for a personal services agency o Change of ownership of direct owner Submit these changes to: Indiana State Department of Health, Acute Care Division, Section 4A-07 2 North Meridian Street Indianapolis, Indiana 46204

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AGENCY NAME Agency Name: The personal services agency may not advertise as a home health agency. According to IC 16-27-1-15 Sec.15. A person who: (1) operates a home health agency; or (2) advertises the operation of a home health agency; that is not licensed commits a Class A misdemeanor. SECTION VIII - LICENSE FEE

Return the initial application, required documents and a non-refundable license fee of $250.00 payable to Indiana State Department of Health to: Indiana State Department of Health Cashier's Office P.O. Box 7236 Indianapolis, Indiana 46207-7236

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