Free 53398.pdf - Indiana

APPLICATION FOR REGISTRATION TO OPERATE AN OUT OF STATE MOBILE HEALTH CARE ENTITY
State Form 53398 (8-07)

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INDIANA STATE DEPARTMENT OF HEALTH-DIVISION OF ACUTE CARE

Division of Acute Care Use Only Date Received__________________
(month/day/year)

Date Approved__________________
(month/day/year)

· · ·

All questions on this application must be answered completely in printed or typed script. Supporting documentation must be attached. AN INCOMPLETE OR ILLEGIBLE APPLICATION WILL BE RETURNED WITHOUT BEING PROCESSED. Registration and/or approval renewal must be obtained annually. This application and the registration, and/or approval which may be issued as a result, are neither assignable nor transferable.

Please Type or Print Legibly SECTION I - TYPE OF APPLICATON Application (check appropriate item)
Change of Ownership (Anticipated date of Sale/Purchase/Lease)________________________ Submit a dated and signed copy of the bill of sale, lease or other document of transfer. New Agency Renewal

SECTION II - IDENTIFYING INFORMATION A. Out of State Mobile Health Care Entity Parent Location (name of agency d/b/a of direct owner))
If the d/b/a name is different from the direct owner submit a "Certificate of Doing Business Name" document from the Indiana Secretary of State that lists the direct owner and "doing business as" (d/b/a) name. Name of agency Street address (number and street) City Telephone number ( ) E-mail address Fax number ( ) Web address County Agency's office hours (i.e. 8:00 a.m. ­ 4:00 p.m.) Monday Tuesday Wednesday Thursday P.O. Box ZIP Code +4

Friday

Saturday

Sunday

B. Mailing Address (if different from practice location)
Street address (number and street) City State P.O. Box ZIP Code +4

C. Ownership Information (direct owner of the agency d/b/a)
The owner as registered with the Indiana Secretary of State and appears on the Articles of Incorporation, Certificate of Incorporation or Certificate of Organization, Certificate of Assumed Business Name, etc. Owner of the agency

Street address (number and street)

P.O. Box

City

State

ZIP Code+4

Telephone number ( )

Fax number ( ) Fiscal year end date (mm/dd)

EIN Number (submit documentation to validate)

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D. States, foreign countries or provinces entity is registered or licensed in. Provide copy of each state/country/province registration or license (IC 16-41-42-1)

E. Name of company(s) affiliated with Out of State Mobile Health Care Entity (IC 16-41-42-5)
Name Address (street address/city/ZIP Code) Telephone Number

SECTION III ­ STAFFING A. Employees currently in good standing licensed, certified, or registered in a health care profession in Indiana or any other state. Provide copy of employee's license, certification or registration. (IC16-41-42-5)
Last Name First Name Initial

B. Health Care services to be provided under a contract (IC 16-41-42-5) Provide copy of contract and license/certification/registration.
Last Name First Name Initial

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C. Health care services, health care tests and equipment that the health care entity will perform or use. (IC 16-41-42-5(4))
Health Care Service performed Health Care Tests performed Equipment used

D. Describe the manner in which test results and recommendations for health care based on the results are disclosed to the patient. (IC 16-41-42-5) Provide copy of a sample report.

SECTON IV - OWNERSHIP A. Type of Ownership (applicable for change of ownership only ­ do not complete if initial application)
Asset Purchase Agreement Merger Termination of Lease Assignment of Interest New Partnership Transfer of Asset Agreement Lease Sale Other ______________________

Submit a bill of sale or comparable document, which includes corporation/owner(s) name(s) and buyer/seller signature(s) and effective date of transaction with the application.

B. Type of Entity For Profit
Individual Partnership Corporation Limited Liability Company Sole Proprietorship Other (specify) _____________________________ _____________________________________________

NonProfit
Church Related Individual Partnership Corporation Limited Liability Company Other (specify) _____________________ _____________________________________

Government
State County City City/County Federal Other (specify) _________________ ________________________________

Submit applicable document from the Indiana Secretary of State



If a Limited Partnership, submit a copy of the "Application for Registration" and "Certificate of Registration" signed by the Indiana Secretary of State. If a Corporation, submit a copy of the "Articles of Incorporation" and "Certificate of Incorporation" signed by the Indiana Secretary of State. If applicant is out of state corporation (foreign corporation), submit a copy of the "Certificate of Authority" to do business in the State of Indiana signed by the Indiana Secretary of State. If a Limited Liability Company, submit a copy of the "Articles of Organization" and the "Certificate of Organization" signed by the Indiana Secretary of State. If the "doing business as" (d/b/a) name is different from the corporation's direct owner's name submit "Certificate of Assumed Business Name" signed by the Indiana Secretary of State.

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SECTION V - CERTIFICATION OF APPLICATION
The undersigned hereby makes application for a registration to operate a Mobile Health Care Entity in the State of Indiana, and in support of this application, represents and shows that the owners and operators are of reputable and responsible character, are able to comply with IC 16-4142, and will operate and maintain this entity in accordance with those requirements. I hereby certify that the operational policies of the entity will not provide for discrimination based upon race, color, creed or national origin. 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 regulations, laws and rules governing the regulation of Mobile Health Care Entities in Indiana.
President/Chairperson/CEO (typed) Signature of President/Chairperson/CEO Mobile Medical Unit Manager (typed) Signature of Mobile Medical Unit Manager Date of Signature (month, day, year) Date of Signature (month, day, year)

SECTION VI - REQUIRED DOCUMENTS TO BE SUBMITTED WITH REGISTRATION APPLICATION
Submit the documentation as defined in IC 16-41-42. Documents from the Indiana Secretary of State (submit applicable documentation): (a) If a limited Partnership, submit a copy of the "Application for Registration" and "Certificate of Registration" signed by the Indiana
Secretary of State.

(b) If a Corporation, submit a copy of the "Articles of Incorporation" and "Certificate of Incorporation" signed by the Indiana Secretary of State. (c) If applicant is an out of state corporation (foreign corporation), submit a copy of the "Certificate of Authority" to do business in the State of Indiana signed by the Indiana Secretary of State. (d) If a Limited Liability Company, submit a copy of the "Articles of Organization" and the "Certificate of Organization" signed by the Indiana Secretary of State. (e) If the "doing business as" (dba) name is different from the corporation's (direct owner) name submit "Certificate of Assumed Business Name" or "Articles of Incorporation" that list the owner and d/b/a name signed by the Indiana Secretary of State. (f) Submit a SS-4 or comparable document from the Internal Revenue Service that reflects direct owner's name, d/b/a if applicable and EIN number or social security number.

Return the application and required documentation to: Indiana State Department of Health Acute Care Division 4A-07 2 N. Meridian St. Indianapolis, Indiana 46204

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