State Form 44885 - Application For License To Operate A Hospital
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4APPLICATION 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
(
)
(
)
B. Mailing Address (if different from hospital location)
Street Address
P.O. Box
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:
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