Get Mn Mdh Fpc931 2019-2025

This guide provides step-by-step instructions for completing the MN MDH FPC931 form, which is essential for registering a Supplemental Nursing Services Agency in Minnesota. Ensuring accurate and complete information helps facilitate a smooth registration process.

Follow the steps to fill out the MN MDH FPC931 online.

1. Click ‘Get Form’ button to obtain the MN MDH FPC931 form and open it for editing.
2. Begin by filling out Section A: Identification. Provide your agency's name, street address (ensure a physical address is included), city, state, zip code, phone number, hours of operation, email address, after-hours contact number, fax number, and the counties where your agency operates.
3. Complete Section B: Ownership. Specify the ownership code that best describes your agency (governmental, nonprofit, etc.), and provide the name of the responsible entity. Include the federal and state tax IDs required, and if applicable, attach your articles of incorporation and current by-laws.
4. In Section C: Management Agent, input the name and address of any management agent, if different from the owner.
5. Section D requires information about the officers and members of the governing body. You can attach a list if necessary or check the box if not applicable.
6. For Section E: Employee Licensing, verify that all employees meet licensing and training standards. Provide an authorized signature and title.
7. If this is a renewal application, answer Section F regarding past services provided and supply the last date of service and facility name.
8. In Section G, outline what other licenses the owner holds, the start date of your agency's services, and detail the types of nursing services offered, including the approximate number of employees per category.
9. Complete Section H: Verification/Registration Fee by certifying the information is accurate and submitting the annual fee of $2,035. Include the signature of an authorized representative along with their printed name, title, and date.
10. Finally, ensure all required documents, such as policies, articles of incorporation, insurance proof, and compliance evidence, are attached as per the checklist at the end of the form.
11. Once you have filled out the form, you can save your changes, download a copy for your records, print it for submission, or share the completed form with relevant parties.

Start completing your MN MDH FPC931 form online today for a seamless registration process.