Free 51054.pdf - Indiana


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Date: May 27, 2005
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State: Indiana
Category: Government
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SUPPLEMENTARY INFORMATION TO FEDERAL APPLICATION RURAL HEALTH CLINIC (RHC)
State Form 51054 (R/4-05)

INDIANA STATE DEPARTMENT OF HEALTH - DIVISION OF ACUTE CARE

Division of Acute Care Use Only Date Received__________________ Date Approved__________________

THE APPLICTION MUST BE COMPLETED IN ITS ENTIRETY IN ORDER FOR ISDH TO PROCESS THE APPLICATION Please Type or Print Legibly SECTION I - TYPE OF APPLICATON Application (check appropriate item)

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 Facility



Other

SECTION II - IDENTIFYING INFORMATION A. Practice Location (name of facility-practice location)d/b/a of direct owner (entity)
If the d/b/a is different from the direct owner submit Articles of Incorporation from the Office of the Secretary of State listing the d/b/a. The d/b/a should be registered with the Office of the Secretary of State and appear on the Articles of Incorporation submitted to ISDH with the application. Name of Agency Street Address P.O. Box

City

County

Zip Code +4

Telephone Number ( )

Fax Number ( )

Facility's office hours (i.e. 8:00 a.m. 4:00 p.m. Monday - Friday)

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

City

State

Zip Code +4

C. Ownership Information (direct owner (entity) of the rural health clinic (d/b/a)
The owner/entity as registered with the Office of Secretary of State and appears on the Articles of Incorporation form submitted to ISDH. Submit Articles of Incorporation from the Office of Secretary of State along with a W9 or other comparable document from the Internal Revenue Service that reflects your corporation name, d/b/a if applicable and EIN number. Ownership (Operator(s) of the facility-practice location) The owner-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. Provider Based
Is this facility a provider based facility?

Yes No

(Is yes, provide provider Medicare number)

If yes, please submit the documentation requested on the enclosed Provider Based Designation letter.

SECTION III - UDERSERVED AREA
Is the clinic designated as in underserved area?

Yes No

SECTION IV STAFFING AND STAFFING RESPONSIBILITIES A. Administrator (office manager)
Name (enter full name)

B. Physician/MD
A physician is present for sufficient periods of time, at least once in every 2 week period (except in extraordinary circumstances), to provide the medical direction, medical care services, consultation and supervision and is available through direct telecommunication for consultation, assistance with medical emergencies, or patient referral. Refer SOM: 491.8 Staffing and Staff Responsibilities. Name (enter full name) Submit a current copy of the physician's Indiana license (billfold size) Days/hours available (i.e, Monday 2 hrs, Tuesday 4 hrs)

Responsibilities

C. Physician Assistant/Nurse Practitioner/Certified Nurse Midwife
A nurse practitioner or a physician assistant must be available to furnish patient care services at least 60 percent of the time the clinic operates. Refer SOM: 491.8 Staffing and Staff Responsibilities. A physician assistant or nurse practitioner in addition to the physician is required for clinic eligibility. (select appropriate box)



Physician Assistant



Nurse Practitioner



Certified Nurse Midwife

Submit a current copy of the physician assistant, nurse practitioner and/or certified nurse midwife Indiana license (billfold size). Name of Physician Assistant (enter full name) Days/hours available (i.e, Monday 2 hrs, Tuesday 4 hrs)

Responsibilities

Name of Nurse Practitioner (enter full name)

Days/hours available (i.e, Monday 2 hrs, Tuesday 4 hrs)

Responsibilities

Name of Certified Nurse Midwife (enter full name)

Days/hours available (i.e, Monday 2 hrs, Tuesday 4 hrs)

Responsibilities

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SECTON V - OWNERSHIP OF APPLICANT ENTITY A. Ownership Information (officers/directors/managing agents/managing employees of the rural health clinic)
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, 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. (use additional sheet if necessary) Name

Title

Business Address (street address/city/state/zip)

B. Type of Change in Ownership (applicable for change of ownership only do not complete if initial application)



Asset Purchase Agreement



Assignment of Interest



Lease

Merger

New Partnership

Sale

Termination of Lease

Transfer of Asset Agreement

Other ______________________

C. Type of Entity (Complete for initial and change of ownership applications)

For Profit

NonProfit

Government



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



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

_____________________________________________ _____________________________________________ _____________________________________________

_____________________________________ _____________________________________ _____________________________________



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

________________________________ ________________________________

If a Limited Partnership, submit a copy of the "Application For Registration" and Certificate of Registration" signed by the Indiana Secretary of State. If a Corporation, submit a copy of the "Articles of Incorporation" and "Certificate of Incorporation" signed by the Indiana Secretary of State. If a foreign Corporation, submit a copy of the "Certificate to do Business in the State of Indiana" signed the Indiana Secretary of State. 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. If the "doing business as" (dba) name is different from the corporation's (direct owner) name submit "Articles of Incorporation" signed by the Indiana Secretary of State that list the d/b/a name. Submit a W9 or other comparable document from the Internal Revenue Service that reflects your corporation name, d/b/a if applicable and EIN number.

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Applicant's signature or signature of authorized agent should appear below
Signature of Authorized Representative

Title

Date

NOTIFY THE INDIANA STATE DEPARTMENT OF HEALTH IN WRITING OF ANY CHANGES IN YOUR STAFF AND/OR SERVICES SUBMIT CHANGES TO: INDIANA STATE DEPARTMENT OF HEALTH ACUTE CARE DIVISION PHNSS-PROGRAM DIRECTOR 2 NORTH MERIDIAN STREET SECTION 4A 07 INDIANAPOLIS IN 46204

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