Get Initial Application For License To Operate A Home ...

Completing the initial application for a license to operate a home health agency is a vital step in ensuring compliance with health regulations. This guide provides clear instructions on how to effectively fill out each section of the application online.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the application form and open it in the editor.
2. Begin with Section I, where you indicate the type of application: 'New Facility' or 'Change of Ownership'. Ensure you check the appropriate box.
3. In Section II, provide identifying information. Fill out the practice location details along with the agency name, address, telephone numbers, and contact email. Make sure to use clear and legible text.
4. Still in Section II, fill in the licensing information about the owner. Ensure to include the EIN number and provide necessary supporting documents like the Articles of Incorporation.
5. Proceed to Section III, which focuses on staffing. You will need to fill out information for the administrator, including their name, qualifications, and any required supporting documents such as resumes and licenses.
6. In Section IV, disclose ownership information. List all individuals or organizations that have a direct or indirect ownership interest, providing their names and addresses.
7. Continue to Section V, where you will provide details about the licensure and operating history of the owners or managers of the agency. Answer yes or no to questions about any prior legal issues.
8. In Section VI, provide management information, including the name and address of the managing company along with the chief executive officer's details.
9. Complete Section VII by certifying the application, ensuring that all statements are accurate and that the operational policies adhere to non-discrimination laws.
10. Finally, review Section VIII to ensure you include all required documentation with your application, including payment of the non-refundable application fee of $250.
11. Save changes to your application, and then download, print, or share the completed form as necessary.

Start your application process online today to ensure a smooth licensing experience.