Free 52569.FH11 - Indiana

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APPLICATION FOR PROVISIONAL LICENSE
State Form 52569 (R / 11-08) Approved by State Board of Accounts, 2008

INDIANA STATE BOARD OF HEALTH FACILITY ADMINISTRATORS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2051 E-mail: [email protected]

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Your Social Security number is requested by this agency in accordance with IC 4-1-8-1, and it is mandatory that it be given. FOR OFFICE USE ONLY

Application fee Date of issuance (month, day, year)

Date fee paid (month, day, year) Provisional license number

Receipt number

DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION
Name of applicant (last, first, middle, maiden) Social Security number *

Address (number and street or rural route)

City

State

ZIP code

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Telephone number (daytime)

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Email address

Date of birth (month, day, year)

Place of birth

WORK EXPERIENCE You must have at least two (2) years of administrative experience in a licensed health facility to qualify for a provisional license [840 IAC 1-1-14 (a)]. Please attach a complete resume documenting your administrative experience. Include your employer, position, type of business, period of time worked, duties, type of facility (SNF, ICF, etc.) and number of beds in the facility. The provisional license can only be used in the licensed health facility that is specified on page three (3) of this application.

If your answer is Yes to any of the following, explain fully in a sworn affidavit, including all related details. Describe the event including the location, date and disposition. Falsification of any of the following is grounds for permanent revocation of a license or permit issued pursuant to this application. 1. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit that you hold or have held? 2. Have you ever been denied licensure, registration, or certification in any state (including Indiana) or country? 3. Are you now being or have you ever been treated for drug or alcohol abuse? 4. Have you ever been convicted of, pled guilty or nolo contendre to any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines) 5. Have you ever been denied staff membership or privileges in any hospital or health care facility or had such membership or privileges revoked, suspended or subjected to any restrictions, probation or other type of discipline or limitations? 6. Have you ever been terminated, reprimanded, disciplined or demoted in the scope of your practice as any healthcare professional? APPLICATION AFFIRMATION I hereby swear or affirm under the penalties of perjury that the statements made in this application are true, complete and correct.
Signature of applicant Date (month, day, year)

Yes Yes Yes Yes

No No No No

Yes

No

Yes

No

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AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, officer, corporation, association, organization, or institution to release to the Professional Licensing Agency any files, documents, records, or other information pertaining to the undersigned requested by the Agency or any of its authorized representatives, in connection with the processing of my application for a health facility administrators provisional license. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations, and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Professional Licensing Agency to disclose to the aforementioned persons, firms, officers, corporations, associations, organizations and institutions, any information which is material to my application, and I hereby specifically release the Agency, and the Board, from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force and effect as the original. AFFIRMATION I hereby swear and affirm that I have read the above statements and agree to the same.
Signature of applicant Date signed (month, day, year)

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THE FOLLOWING MUST BE COMPLETED BY THE HEALTH FACILITY OWNER OR AN OFFICER OF THE FACILITYS BOARD OF DIRECTORS
This is a request for a provisional license as set out in IC 25-19-1-3 (b), which states: (b) The board may issue a provisional license for a single period not to exceed six (6) months for the purpose of enabling a qualified individual to fill a health facility administrator position that has been unexpectedly vacated. Before an individual is issued a provisional license, the individual must fulfill the requirements in subdivision (a) (1) in addition to complying with other standards and rules established by the board. Please attach a detailed explanation of the reason(s) the provisional license is being requested. This information must be included with the application for the Board to consider your request.
Name of prospective individual (last, first, middle) Name of health facility Address of facility (number and street or rural route) City Telephone number of facility State Number of beds in facility ZIP code

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Type or level of care provided

VERIFICATION I hereby swear or affirm under the penalties of perjury that the statements made in this application are true, complete and correct.
Signature of owner or officer Title Date (month, day, year)

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