Get Me Form 090103 2019-2026

This guide provides clear and comprehensive instructions for completing the ME Form 090103 online, specifically designed for users applying for a license to operate an end stage renal disease facility. Follow these steps to ensure accurate and successful submission.

Follow the steps to complete the ME Form 090103 effectively.

1. Click the ‘Get Form’ button to access the form and open it in your online editor.
2. In Section 1, provide the facility information including the facility name, doing business as (if applicable), mailing address, city, state, zip code, county, physical address, and contact details such as telephone number, fax number, and email address.
3. Section 2 requires you to select whether you are submitting a new application or a renewal application, each with a non-refundable fee of $450. Fill in the total fees and the license renewal period, then include the total amount enclosed for submission.
4. In Section 3, indicate the type of entity (for profit, not-for-profit, or public). If applicable, provide the name and address of the president of the board of directors or municipal government representative.
5. Section 4 asks for the name and title of the person in charge, their home address and contact numbers, and information regarding whether the facility is hospital-based or SNF-based. Provide details of any multi-facility organization, including geographic area served, the parent organization’s name and contact information, and services provided.
6. In Section 5, ensure you attach all required documentation, including a check or money order, any leases for the building(s) used, and letters from municipal officials indicating compliance with local ordinances.
7. Finally, in Section 6, certify that all information provided is true and correct by filling in the administrator's name, signing, and dating the application to complete it.
8. After finishing the form, save your changes, then proceed to download, print, or share the completed form as needed.

Complete and submit your ME Form 090103 online today to ensure efficient processing of your application.