Hospital Certificate Of Approval (Page 17 of 18) in pdf

Hospital Certificate Of Approval Page 17

F-62092 (Rev. 07/08)

Page 17

1. Has any adverse action initiated by any state licensing agency resulted in the denial (D), suspension (S), or

revocation (R) of a license?

Yes

If “yes,” please complete the following table. Use abbreviations to describe the type of adverse action and refer to

IV.G.1. for abbreviations for type of health care provider.

Type of Health

Type of

Effective Dates of

Facility Name and Address

City and State

Care Provider

Adverse Action

2. Has any adverse action been initiated by a state or federal agency based on noncompliance resulted in civil money

penalties (CMP), termination of provider agreement (TPA), suspension of payments (SOP), or the appointment of

temporary management of the facility (TMF)?

Yes

If “yes,” please complete the following table. Use abbreviations to describe the type of adverse action and refer to

IV.G.1. for abbreviations for type of health care provider.

Type of Health

Type of

Effective Dates of

Facility Name and Address

City and State

Care Provider

Adverse Action

E. COPY OF MANAGEMENT CONTRACT

Attach a copy of the signed contract with the management company.

VII. CONTACT PERSON

Identify the person responsible for completing this application and who can be contacted to address questions.

Name – Contact Person (Print.)

Title

Telephone Number

Fax Number

Date Application Completed

VIII. DESIGNEE

Identify the person authorized to accept personal service and receive registered and certified mail.

Is the administrator also the Designee?

Yes

If “no,” provide the following information.

Name – Designee

Title

Hospital Certificate Of Approval Page 17