Form Sf 43813 - Application For License Approval To Operate A Hospice Program - Indiana Department Of Health

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Division of Acute Care
APPLICATION FOR LICENSE
APPROVAL TO OPERATE A HOSPICE PROGRAM
(PURSUANT TO IC 16-25-3)
Form approved by State Board of Accounts, 1999
SF 43813 (R2/7-99)
1. All questions on this application must be printed or typed and answered completely
with supporting documentation attached. Incomplete or illegible applications will be
returned without being processed.
2. License and/or Approval renewal must be obtained annually.
3. This application and the License or Approval which may be issued as a result, are
neither assignable nor transferable.
4. Previous receipt of a Certification is not a guarantee that a License or Approval will
be issued.
5. A non-refundable application fee in the amount of $100.00 must accompany this
application. No License or Approval shall be issued without receipt of this fee.
6. Mail this application, accompanying documentation and non-refundable fee to:
Indiana State Department of Health
Division of Acute Care
Section 4A
2 North Meridian Street
Indianapolis, Indiana 46204
A. APPLICANT/OWNER INFORMATION
1. Name of hospice program _______________________________________________
Street Address ________________________________________________________
City ______________________ County _________________ Zip Code __________
Telephone _______________________ Fax number __________________________
Employer identification number __________________________________________
Name of owner/operator (if different than above) ____________________________
Street Address ________________________________________________________
City ______________________ County _________________ Zip Code __________
Telephone _______________________ Fax number __________________________
Employer identification number __________________________________________
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