State Form 9340 - Application For License To Operate An Ambulatory Outpatient Surgical Center Page 4

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License Fee
Select the appropriate license fee below and return the application, any attachments, and
license fee to:
INDIANA STATE DEPARTMENT OF HEALTH
CASHIER’S OFFICE
P. O. BOX 7236
INDIANAPOLIS, INDIANA 46207-7236
Total Annual Procedures are found on the fourth quarter report entitled “Quarterly
Utilization Review Report/Ambulatory Surgery Center (State form 49933),” item III, line
“Since the beginning of the year”, right hand box.
Check
Total Annual Procedures
Fee
One
Zero to 799
$500.00
800 to 3,499
$1,000.00
3,500 to 6,999
$2,000.00
7,000 and above
$3,000.00
Indiana Hospital Council; 414 IAC 1-2
4

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