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

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

D.
Name(s) and address(es) of Hospital(s) with which there is a written agreement for acceptance of
referred patients:
_______________________________________________________________________________
Name
Location
______________________________________________________________________________
Name
Location
E. Services Provider:
Ancillary Services
1. Laboratory _____
2. Radiology _____
3. EKG _____
4.. Pharmacy _____
Surgical Specialties
1. Cardiovascular _____
2. Foot _____
3. General _____
4. Neurological _____
5. Obstetrics/Gynecology _____
6. Opthamology _____
7. Oral _____
8. Orthopedic _____
9. Otolaryngology _____
10. Plastic _____
11. Thoracic _____
12. Urology _____
13. Other (specify) _____
F. Number of Operating Rooms _________________________
I hereby certify under penalties of perjury that the information
contained herein is true and accurate.
G.
Signature __________________________________________________________________
Owner/Chairman
Date ________________________
Printed Name & Title ________________________________________________________
Signature _________________________________________________________________
Facility Administrator
Date ________________________
Printed Name & Title _______________________________________________________
Return application to:
Indiana State Department of Health
Attn: Acute Care Division – Section 4A
2 N. Meridian Street, Indianapolis, IN 46204

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