Form Sf 43813 - Application For License Approval To Operate A Hospice Program - Indiana Department Of Health Page 2

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2. Does the applicant intend to operate more than one site?
Yes o No o
If yes, on a separate sheet, please provide a list of each additional site, including
address, and phone number.
3. Is this hospice owned by a separately licensed entity?
Yes o
No o
If yes, please check the appropriate box and give the license information in the space
provided.
Hospital o
Health Facility o
Home Health Agency o
Other o
License number (include a copy with application) ___________________________
Date issued________________
Date expires________________________
4. Has applicant been previously licensed or received a certification for operation of a
hospice from the Division?
Yes o
No o
If yes, please provide the license or certificate number (include a copy with
application) ______________________________
5. What geographic service area does applicant serve? Please identify by city, county
and township. ________________________________________________________
____________________________________________________________________
____________________________________________________________________
If the geographic service area is different from that previously served by applicant,
please state, describing the previous service area and reason for change.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
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