Ohio Administrative Code
Title 4729:11 - HME Services
Chapter 4729:11-2 - HME Services Provider
Section 4729:11-2-03 - Applications
Universal Citation: OH Admin Code 4729:11-2-03
Current through all regulations passed and filed through March 18, 2024
(A) The following information shall be required on a form supplied by the state board of pharmacy from each person making an application for a HME services provider license or certificate of registration:
(1)
The name, full
physical business address (not a post office box), and telephone number of the
applicant.
(2)
All trade, fictitious, or business names used by the
applicant (e.g. "doing business as" or "formerly known as").
(3)
Addresses,
telephone numbers, and the full names of contact persons for all facilities
used by the applicant for the storage, handling, and distribution of
HME.
(4)
The type of ownership or operation (i.e., sole
proprietorship, partnership, corporation, or government
agency).
(5)
The following information for the owner(s) and/or
operator(s) of the applicant:
(a)
For a partnership:
(i)
The full name,
business address, social security number, and date of birth of each partner; if
the partner is not a natural person each business entity that is a partner
having an ownership interest must be disclosed on the application up to and
through the entity that is owned by a natural person;
(ii)
The name of the
partnership; and
(iii)
The partnership's federal employer identification
number.
(b)
For a corporation:
(i)
The full name,
business address, social security number and date of birth of the corporation's
president, vice-president, secretary, treasurer and chief executive officer, or
any equivalent position;
(ii)
The name or names of the corporation;
(iii)
The state of
incorporation;
(iv)
The corporation's federal employer identification
number;
(v)
The name of the parent company, if
applicable;
(vi)
If the corporation is not publicly traded on a major
stock exchange, the full name, business address, and social security number of
each shareholder owning ten percent or more of the voting stock of the
corporation.
(c)
For a sole proprietorship:
(i)
The full name,
business address, social security number, and date of birth of the sole
proprietor; and
(ii)
If applicable, the federal employer identification
number of the business entity.
(6)
If the person
making application for a certificate of registration, information necessary to
verify accreditation authorized pursuant to rule 4729:11-2-04 of the Administrative Code.
(7)
If applicable, the Ohio medicaid number, federal
medicare number, and federal tax identification number for the
applicant.
(8)
A copy of the applicant's certificate of product and
professional liability insurance from an insurer showing a minimum one million
dollars per occurrence, three million dollars aggregate of
coverage.
(9)
A list of the HME to be stored, repaired, leased or
sold by the applicant.
(10)
A brief description of the HME services provided,
including square footage of the facility.
(11)
A list of the
personnel currently employed by the applicant who are engaged in the delivery
of HME services, including job titles.
(12)
List of other
licenses, registrations, or certifications held by the
applicant.
(13)
Any additional information required on the application
as determined by the board.
(14)
Any follow-up
information as deemed necessary upon the receipt of the application
materials.
Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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