Get Form Approved 10/14/2014

This guide provides a step-by-step process for completing the Form Approved 10/14/2014 online. This form is essential for the application for licensure for adult medical day care facilities, ensuring you provide all necessary information clearly and accurately.

Follow the steps to complete your application online.

1. Click ‘Get Form’ button to access the form and open it in your browser.
2. In the general information section, check the type of application you are submitting: initial, renewal, change of ownership, change of location, name change, or change in capacity. Provide your legal agency name, trading name (if applicable), email address, phone number, business address, and mailing address.
3. Fill out the details of the director including their name, phone number, and cell number. Ensure that you include the license number of the registered nurse overseeing responsibilities along with their license expiration date.
4. Complete the business hours section in HH:MM format, specifying the hours that staff are present for each day of the week.
5. Indicate the total number of participants and whether the AMDC is attached to a nursing home or is a freestanding building.
6. List all health care services provided by the center, including physical therapy, occupational therapy, and any additional services. Specify if these services are provided by staff or through contracts.
7. In the ownership section, identify your type of business organization and provide relevant details for each partner or stockholder owning 25% or more.
8. If you have employees, provide your workers' compensation insurance information, including policy number and insurance company. If you do not have employees, be prepared to submit additional documentation as instructed.
9. Read and complete the affidavit section, affirming that all provided information is true and compliant with relevant regulations. Sign and date the application, ensuring all required signatures are included if multiple applicants are involved.
10. Finally, after reviewing all entries for accuracy, save your changes, and choose to download, print, or share the completed form as needed.

Complete your adult medical day care application online today!