Get Ky Oig 003 2017-2025

The KY OIG 003 is a crucial form for those looking to apply for a license to operate a hospital in Kentucky. This guide provides clear, step-by-step instructions to help users navigate the online completion of the form effectively.

Follow the steps to complete the KY OIG 003 form online.

1. Click ‘Get Form’ button to access the KY OIG 003 and display it in your online editor.
2. Identify the type of application you are submitting. Mark an X next to all applicable options, such as provisional licensure or change of ownership.
3. Provide identification details, including the license number if applicable, name of the facility, and its physical location including street, city, county, state, and zip code. If the mailing address differs, complete that section as well.
4. Input the contact information, including the telephone number and email address of the primary person for correspondence. Include the name of the facility administrator.
5. Indicate the dates for when the facility began operating at its current address and under the current owner.
6. In the control section, specify the state, county, and city and indicate if it is private.
7. Select one option from each column under ownership to clarify the type of ownership structure.
8. Detail the name and address of the direct owner and ensure to attach the required supporting documentation.
9. Indicate the type of license you are applying for by marking an X next to the relevant type of hospital and providing the number of currently licensed beds and any requested changes.
10. Include attachments as needed for outpatient services and provider-based entities associated with the hospital.
11. Review the acknowledgment details, ensuring understanding of compliance requirements, and prepare to sign off in the space provided for the authorized representative.
12. After completing all sections, proceed to save changes, download, print, or share the completed form as needed.

Complete your application for the KY OIG 003 online today!