Get In State Form 4008 2017-2025

Filling out the IN State Form 4008 online can streamline the process of applying for a license to operate a home health agency in Indiana. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to complete the application form successfully

1. Press the ‘Get Form’ button to access the application form online.
2. Begin with Section I, where you must select the type of application by checking the appropriate box, either for a new facility or a change of ownership. If it's a change of ownership, provide the anticipated date of sale, purchase, or lease.
3. Proceed to Section II and fill out the identifying information. Include the practice location, agency name, address, and contact details. Make sure that the d/b/a is properly registered with the Indiana Secretary of State.
4. For licensee/ownership information in Section II B, provide details regarding the owner or entity as registered, including address and EIN number, and attach required documentation reflecting the owner/entity name.
5. In Section III, fill out staffing information. Include the names and qualifications of the administrator, alternate administrator, clinical supervisor, and alternate clinical supervisor. Attach the relevant resumes and criminal history checks as required.
6. Continue to Section IV, where you will disclose ownership and controlling interests. List names and addresses of individuals or organizations with a controlling interest of five percent or more.
7. In Section V, disclose any prior licensure or operating history issues for owners or management personnel. If applicable, provide complete explanations for any issues noted.
8. Complete Section VII by certifying the application. Ensure that the applicant’s signature or the signature of an authorized agent is included along with the date signed.
9. Finally, in Section VIII, ensure you collect and attach all required documentation and the non-refundable application fee of $250. Review your form for completeness before submission.
10. Once finalized, save your changes, and if required, download, print, or share the completed IN State Form 4008 for your records or submission.

Complete your IN State Form 4008 online today to facilitate your application for a home health agency license.