State Form 9340 - Application For License To Operate An Ambulatory Outpatient Surgical Center

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APPLICATION FOR LICENSE
TO OPERATE AN AMBULATORY OUTPATIENT SURGICAL CENTER
State Form 9340 (R5/6-04)
Indiana State Department of Health-Division of Acute Care
(Pursuant to IC 16-21-2 and 410 IAC 15-2.3-1 )
Form Approved By State Board Of Accounts-2004
Division of Acute Care Use Only
Date Received__________________
Date Approved__________________ Date Rejected __________________
Please Type or Print Legibly
SECTION I - TYPE OF APPLICATION
Application (check appropriate item)
•
•
•
New Facility
Renewal
Change of Ownership (Anticipated date of Sale/Purchase/Lease)__________________
Submit a dated and signed copy of the bill of sale, lease or other document of transfer
SECTION II - IDENTIFYING INFORMATION
A. Surgical Center Location
Name of Surgical Center
Street Address
P.O. Box
City
County
Zip Code +4
Telephone Number
Fax Number
Hours Procedures are Performed (if no procedures performed indicate “closed”):
(
)
(
)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
B. Mailing Address (if different from surgical center location)
Street Address
P.O. Box
City
County
Zip Code +4
C. Licensee/Ownership Information
Licensee: The applicant entity as registered with the secretary of state
Street Address
P.O. Box
City
State
Zip Code+4
Telephone Number
Fax Number
EIN Number
Fiscal Year End Date (mm/dd)
(
)
(
)
D. Supplier Numbers
Medicare Supplier Nu mber:
15C____________________
Medicaid Supplier Number (Related Supplier Number):_________________________
1

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