State Form 8200 - Application For License To Operate A Health Faclity - Indiana State Department Of Health

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APPLICATION FOR LICENSE
TO OPERATE A HEALTH FACLITY
(Pursuant to IC 16-28 and 410 IAC 16.2)
State Form 8200 (R3/08-00)
Indiana State Department of Health-Division of Long Term Care
DIVISION OF LONG TERM CARE
Date Received________________________________
Date Approved________________________________
Approved by__________________________________
Please Print or Type
SECTION I - TYPE OF APPLICATON
Application (check appropriate item)
• •
• •
• •
Change of Ownership (Anticipated date of Sale/Purchase/Lease)__________________
New Facility
Other___________________
SECTION II - IDENTIFYING INFORMATION
A. Practice Location (facility)
Name of Facility
Street Address
P.O. Box:
City
County
Zip Code +4
Telephone Number
Fax Number
Facility’s Cost Reporting Year
From (mm/dd):
To (mm/dd):
(
)
(
)
B. Licensee/Ownership Information
Licensee (Operator(s) of the facility) The licensee and the applicant entity as described in Item IV-A of this application should be the same.
Street Address
P.O. Box
City
State
Zip Code+4
Telephone Number
Fax Number
EIN Number
Fiscal Year End Date
(
)
(
)
(mm/dd)
C. Building Information
1.
Status of building to be used (check appropriate item)
• •
• •
• •
• •
Proposed New Construction
Alteration of Existing Building
Existing Licensed Health Facility
Other__________________________
2.
Type of Construction (materials) (if new, as certified by architect or engineer registered in the state of Indiana)
________________________
________________________
________________________
________________________
D. Type of Services to be Provided
Level of Care
Number of Beds
2.
Certification Designation
Number of Beds
1.
in Each Category
in Each Category
)
(to be licensed)
(to be licensed
____________
____________
• •
• •
Residential
SNF (Title 18 – Medicare)
• •
• •
____________
____________
Comprehensive (Certified)
SNF/NF (Title 18 – Medicare/Title 19 – Medicaid)
• •
• •
Comprehensive (Non-certified)
NF (Title 19 – Medicaid)
____________
____________
• •
• •
____________
____________
Children’s Facility
ICF/MR
• •
Developmentally Disabled
____________
____________
Total Number of Licensed Beds
____________
Total Certified Beds
1

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