Get In Change Of Ownership Application Residential Care Facility 2014-2025

This guide provides comprehensive instructions on completing the IN Change Of Ownership Application for a Residential Care Facility. Following these steps will help ensure your application is submitted correctly and efficiently.

Follow the steps to complete the application process smoothly.

1. Click ‘Get Form’ button to obtain the application form and access it in the editing interface.
2. Begin with the cover letter, which should include your contact name, phone number, email, and address. Ensure this letter is submitted with the application at least 30 days before the intended change of ownership date.
3. Complete State Form 8200, Application for License to Operate a Health Facility. Attach any required documents as specified in the instructions.
4. Fill out State Form 19733, Implementing Indiana Code 16-28-2-6, ensuring all sections are addressed.
5. Gather documentation that proves the applicant entity is registered with the Indiana Secretary of State, including any doing business as (d/b/a) names if applicable.
6. Complete State Form 51996, Independent Verification of Assets and Liabilities, and include all necessary attachments.
7. Prepare the licensure fee, which is $200.00 for the first fifty beds and $10.00 for each additional bed, payable by check or money order to the Indiana State Department of Health.
8. Submit fully executed copies of the Bill of Sale, Lease, Asset Purchase Agreement, or other legal documents that validate the change of ownership, indicating the effective date.
9. Provide IRS documentation that includes the legal entity’s name and Employer Identification Number (EIN), ensuring it is an official document sent by the IRS.
10. Complete State Form 4332, Bed Inventory, to detail the number of beds available in the facility.
11. Draft a facility floor plan on 8 ½” x 11” paper, clearly showing room numbers and the number of beds per room.
12. Fill out SF 55283 Contract and Service Agreement Checklist, along with copies of any new Service Agreements/Contracts with third parties.
13. Complete SF 55282 Proposed Staffing Structure to outline the intended staffing for the facility.
14. Include a copy of the facility’s disaster plan to demonstrate preparedness.
15. After completing all required documents, review for accuracy and completeness before submitting the entire application packet to the Indiana State Department of Health.
16. Once submitted, await confirmation of receipt and subsequent processing of the application.

To avoid delays and ensure a successful application, complete your documents online today.