Form Sf 43813 - Application For License Approval To Operate A Hospice Program - Indiana Department Of Health Page 3

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B. STAFF
1. Medical Director
Name _______________________________________________
Indiana License Number ________________________________
a. Has the medical director ever been convicted of any criminal offense relating
to, or in any way associated with, the provision of health care services?
Yes o
No o
If yes, state on a separate sheet the facts of each case and how it was resolved.
b. Has the medical director’s license (if applicable) lapsed, been suspended or
revoked?
Yes o
No o
If yes, explain on a separate sheet of paper the place, date and agency initiating
action, action taken and reason.
2. Patient/Family Care Coordinator
Name _______________________________________________
Indiana License Number (if applicable) ____________________
a. Has the coordinator ever been convicted of any criminal offense relating to, or
in any way associated with, the provision of health care services?
Yes o
No o
If yes, state on a separate sheet the facts of each case and how it was resolved.
b. Has the coordinator’s license (if applicable) lapsed, been suspended or
revoked?
Yes o
No o
If yes, explain on a separate sheet of paper the place, date and agency initiating
action, action taken and reason.
c. On a separate sheet, please list the coordinator’s complete educational
background and employment history. Include post-secondary education and
health related experience.
3

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