Hospital Certificate Of Approval Page 15
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18F-62092 (Rev. 07/08)
Page 15
Address
Begin Date
City
State
Zip Code
Ownership Percentage
Name
Title
Address
Begin Date
City
State
Zip Code
Ownership Percentage
Name
Title
Address
Begin Date
City
State
Zip Code
Ownership Percentage
Name
Title
Address
Begin Date
City
State
Zip Code
Ownership Percentage
Name
Title
Address
Begin Date
City
State
Zip Code
Ownership Percentage
V. LEASE AGREEMENT
Is there a lease agreement?
Yes
No
If “yes,” list the name and address of the lease holder.
Name
Mailing Address
City
State
Zip Code
Lease Agreement End Date
VI. MANAGEMENT COMPANY
A. MANAGEMENT CONTRACT
Is the operation of the facility under a management contract?
Yes
No
If “yes,” provide the following information regarding any management company retained to operate this facility or
program.
Type of Management Company
Corporation
Partnership
Individual
Government
Name – Management Company
Name – Contact Person
Telephone Number
Address
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