State Form 9340 - Application For License To Operate An Ambulatory Outpatient Surgical Center Pursuant To Ic 16-21-2 - 2000

Download a blank fillable State Form 9340 - Application For License To Operate An Ambulatory Outpatient Surgical Center Pursuant To Ic 16-21-2 - 2000 in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete State Form 9340 - Application For License To Operate An Ambulatory Outpatient Surgical Center Pursuant To Ic 16-21-2 - 2000 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

APPLICATION FOR LICENSE TO OPERATE
AN AMBULATORY OUTPATIENT SURGICAL CENTER
PURSUANT TO IC 16-21-2
State Form 9340 (R3 / 3-00)
The undersigned hereby makes application for license to operate an ambulatory outpatient surgical center
in the State of Indiana; and in support of this application represents and shows that the owners and
operators are able to comply with IC 16-21-2 and its accompanying regulations and will operate and
maintain this facility 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 IN FULL.
A.
Name and Location of Center:
1.
Name ____________________________________________________________________
2.
Location _________________________________________________________________
Street Address
City
State
Zip
County
3. For those facilities with off-sites, please attach a list with name, address, phone and fax
numbers. Please list days and hours of operation for off-site locations.
4. Telephone number ______________________
Fax number _______________________
5. Hours and Days of Operation __________________________________
6. EIN number _______________________________
7. Fiscal year end date _________________________
8. Medicare Provider number ____________________________
B.
Ownership Information:
1. Government ________
Partnership ________ Corporation _________ Other ________
If “Other”, please specify_________________________________________________
C.
1. Proprietary ________
Non-Profit Organization ______
2. Name of Owner(s): __________________________________
3. Address
_______________________________________
4. If incorporated, attach a list of Board members’ names and addresses.
5. Deemed Status Accreditation:
Y / N
If yes, please give name of accrediting body and effective & expiration dates
Name: __________________________________________________
Effective Date: ______________ Expiration Date: _______________
If accredited, please attach a copy of the entity’s accreditation approval letter.
-Please see reverse side-

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

State Form 9340 - Application For License To Operate An Ambulatory Outpatient Surgical Center State Form 9340 - Application For License To Operate An Ambulatory Outpatient Surgical Center Legal
State Form 44885-application For License To Operate A Hospital Pursuant To Ic 16-21-2 State Form 44885-application For License To Operate A Hospital Pursuant To Ic 16-21-2 Business
State Form 8200 - Application For License To Operate A Health Faclity - Indiana State Department Of Health State Form 8200 - Application For License To Operate A Health Faclity - Indiana State Department Of Health Legal
State Form 44885 - Application For License To Operate A Hospital State Form 44885 - Application For License To Operate A Hospital Legal
State Form 29495 - Application For License To Practice Medicine / Osteopathic Medicine In Indiana State Form 29495 - Application For License To Practice Medicine / Osteopathic Medicine In Indiana Legal
State Form 27522 - Application For License To Practice Psychology In Indiana State Form 27522 - Application For License To Practice Psychology In Indiana Legal
Form 4 - Form Of Application For License To Drive A Motor Vehicle Form 4 - Form Of Application For License To Drive A Motor Vehicle Business
Form State Form 46454 - Application For Registration To Practice Engineering Form State Form 46454 - Application For Registration To Practice Engineering Legal
State Form 37911 - Application For Liccense To Practice Speech-language Pathology Or Audiology State Form 37911 - Application For Liccense To Practice Speech-language Pathology Or Audiology Legal
State Form 46159 - Application For Permit To Administer Anesthesia And Sedation For Dentists State Form 46159 - Application For Permit To Administer Anesthesia And Sedation For Dentists Legal

Related Categories

Parent category: Legal
Download
Go
Page of 2