Re-Application For License / Approval To Operate A Hospice - Indiana Department Of Health

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RE-APPLICATION FOR LICENSE / APPROVAL TO OPERATE A HOSPICE
Division of Acute Care
SF 49883 (8-00)
Approved by State Board of Accounts, 2000
FOR DIVISION OF ACUTE CARE USE ONLY
DATE RECEIVED _____________________ DATE APPROVED ___________________ APPROVED BY _________________
The undersigned hereby requests re-application for a license / approval to operate a hospice.
Name of Owner / Operator
Address of Hospice (number and street,, city, state, ZIP code)
Name of Hospice
LIST ADDITIONAL SITES:*
*Attach additional sheets, if necessary.
1. LICENSEE (OWNING ENTITY) ___________________________________________________________________
ä Sole Proprietorship
ä Partnership
ä Corporation
ä Unincorporated Association
ä Other (Specify)_______________
ä Limited Liability Corporation
__________________________
2. FACILITY NAME ________________________________________________________________________________
3. List names and addresses of individuals or organizations having direct or indirect ownership interest of five percent (5%) or more
in the applicant entity. Indirect ownership interest is interest in 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. (Use additional sheet if necessary.)
NAME
MAILING ADDRESS
EIN NUMBER
1

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