Hospital Certificate Of Approval (Page 12 of 18) in pdf

Hospital Certificate Of Approval Page 12

F-62092 (Rev. 07/08)

Page 12

6. Has the applicant ever been convicted of a crime related to the delivery of health care services or items?

Yes

If “yes,” explain.

Has the applicant ever been convicted of a crime involving controlled substances under Chapter 161, Wis. Stats.?

Yes

If “yes,” explain.

Has the applicant had any prior financial failure that resulted in bankruptcy or in the closing of a hospice, home

health agency or an inpatient health care facility, e.g., nursing home or hospital, or the relocation of its patients or

residents?

Yes

If “yes,” explain.

Has the applicant/owner been adjudicated bankrupt?

Yes

If “yes,” explain on a separate page. Provide the dates, court, and disposition of each action.

10. Are there any unsatisfied judgments against the applicant/owner?

Yes

If “yes,” explain on a separate page. Provide the names and addresses of creditors, amounts, and the reasons

for non-payment.

11. Does the applicant / owner owe any debts that are 90 days past due?

Yes

If “yes,” explain on a separate page. Provide the names and addresses of creditors, amounts, and reasons for

non-payment.

12. Does the applicant / owner plan to provide care to patients who are unable to pay for service?

Yes

13.

Attach proof of sufficient resources as may be necessary to operate the facility for at least 90 days. Proof of

sufficient financial resources should include income / expense statements.

14. Financial References

This question is to be completed by the applicant. Include at least one bank. Attach additional pages, if necessary

Hospital Certificate Of Approval Page 12