Form Sf 43813 - Application For License Approval To Operate A Hospice Program - Indiana Department Of Health Page 4

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3. Governing Body
Please list the names and addresses of the Governing Body Officers (use
additional sheets if necessary).
Name
Business Address
_________________________
____________________________________
_________________________
____________________________________
_________________________
____________________________________
_________________________
____________________________________
_________________________
____________________________________
_________________________
____________________________________
4. Does the applicant employ, contract or use home health aides in providing
services to its patients?
Yes o
No o
If yes, please provide a list of all home health aides presently employed, contracted or
used by applicant, along with a copy of the criminal background check and
documentation of applicant’s check of the State Nurse Aide Registry for each such
aide.
5. Does the applicant use volunteers in providing services to its patients?
Yes o
No o
If yes, please provide a list of all volunteers used by applicant, along with a copy
of the documentation of the criminal background check and documentation of
applicant’s check of the State Nurse Aide Registry for each such volunteer who
acts as a home health aide.
C. REPRESENTATIONS
The undersigned hereby makes application for a license to operate a hospice in the State
of Indiana, and in support of this application, represents and shows that the applicant is
able to comply with the hospice licensure/approval statute, IC 16-25-3 and accompanying
regulations.
I swear or affirm under the penalty of perjury that all statements made in this application
and any attachments thereto are correct and complete and that I will comply with all rules
and regulations governing the licensure/approval of Hospice programs in Indiana.
4

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