State Form 44885-Application For License To Operate A Hospital Pursuant To Ic 16-21-2
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1
2APPLICATION FOR LICENSE TO OPERATE A HOSPITAL
PURSUANT TO IC 16-21-2
)
State Form 44885 (R3 /3-00
The undersigned hereby makes application for a license to operate a hospital in the State of
Indiana; and in support of this application represents and shows that the owners and operators are
able to comply Indiana Code IC 16-21-2 and accompanying regulations and will operate and
maintain this hospital in accordance with said regulations. THE UNDERSIGNED ALSO
CERTIFIES THAT THE CIVIL RIGHTS ACT OF 1961 IC 22-9-1, AS AMENDED,
WILL BE COMPLIED WITH IN FULL.
:
A. Name and Location of Institution
1.
Name (dba)___________________________________________________________
Address______________________________________________________________
Street Address
City
State
Zip
County
2.
Name of Owner: (if different than dba)______________________________________
Address_______________________________________________________________
Street Address
City
State
Zip
County
3.
EIN number ____________________________
4.
Please check ONLY if operated under the Hospital License:
______ Blood Center (on/off-site)*
_____ Off-site Clinics*
______ Free-Standing Ambulatory*
_____ Other Off-Site*
Surgical Center
_____ Hospice
_____ Long Term Care Unit
Number of Beds_____
_____ Home Health
Medicare Certified:
Y / N
If yes, Medicare cert. # ___________________
Is LTC unit also licensed by Health Facilities
Y / N
______Extended Care
Number of Beds _____
*Please provide a list of facility names, addresses and phone numbers for off-sites.
5.
Telephone Number__________________ Fax Number________________________
6.
Fiscal Year End Date________________________
7.
Medicare Provider Number__________________________
8.
Medicaid Provider Number__________________________
-Please see reverse side-
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Parent category: Business