State Form 48851 - Renewal Application For License To Operate A Home Health Agency

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RENEWAL APPLICATION FOR LICENSE
TO OPERATE A HOME HEALTH AGENCY
State Form 48851 (R5/6-06)
Indiana State Department of Health-Division of Acute Care
Approved by State Board of Accounts, 2006
Division of Acute Care Use Only
Date Received
__________________
Date Approved
__________________
(month, day, year)
(month, day, year)
All questions on this application must be answered completely and legibly with printed or typed script with supporting
documentation attached when applicable.
Complete all sections on this application. AN INCOMPLETE OR ILLEGIBLE
APPLICATION WILL BE RETURNED WITHOUT BEING PROCESSED.
A non-refundable application fee in the amount of
$250.00 must accompany this application. No license or approval shall be issued without receipt of this fee and/or completed
application.
Please Type or Print Legibly
SECTION I - LABEL IDENTIFICATION/INFORMATION
Agency Name/Address Identification Label
If there is a change in the name of the facility submit
Articles of Incorporation or Certificate of Assumed
Business document from the State of Indiana Office
of the Secretary of State.
Complete all sections of the application.
SECTION II - AGENCY NAME AND ADDRESS
Practice Location
(agency) Complete all sections below
Name of Agency
Street address
P.O. Box
City
County
Zip code +4
Telephone number
Fax number
E-Mail address
Web address
(
)
(
)
SECTION III- MANAGEMENT
Staffing
- Complete all sections below (If there are changes in your staffing, attach a resume, current Indiana RN license, current limited criminal
history check)
Name of Administrator
Name of Alternate Administrator
Name of Nursing Supervisor
Name of Alternate Nursing Supervisor
SECTION IV – BRANCHES
?
Does the agency have branches
Yes
No
If yes, please provide the name, address, and telephone number of each branch location. (Use additional sheet if necessary.)
Name
Address (street address/city/zip code)
Telephone Number
1

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