(a) The application.
(1) An applicant shall not misstate a
material fact on any documents required to be submitted under this
subsection.
(2) The application
form must be accurate and complete and must contain original signatures. The
nonrefundable license fee must be submitted with the application.
(3) The following information must be
submitted on the original application form and the application shall be
notarized:
(A) information on the applicant
including name, street address, mailing address, social security number or
federal tax identification number, and if applicable, date of birth and
driver's license number;
(B) the
name, mailing address, and street address of the center. The street address
provided on the application must be the address from which the center will be
operating and providing services;
(C) a list of names and business addresses of
all persons who own any percentage interest in the applicant including:
(i) each limited partner and general partner
if the applicant is a partnership; and
(ii) each shareholder, member, director, and
officer if the applicant is a corporation, limited liability company or other
business entity;
(D) a
list of any businesses with which the applicant subcontracts and in which the
persons listed under subparagraph (C) of this paragraph hold any percentage of
the ownership;
(E) if the applicant
has held or holds a center license or has been or is an affiliate of another
licensed center, the relationship, including the name and current or last
address of the other center and the date such relationship commenced and, if
applicable, the date it was terminated;
(F) if the center is operated by or proposed
to be operated under a management contract, the names and addresses of any
person and organization having an ownership interest of any percentage in the
management company;
(G) a written
plan for the orderly transfer of care of the applicant's clients and clinical
records if the applicant is unable to maintain services under the
license;
(H) the organizational
structure of the staffing for the center;
(I) the names and addresses of the
physicians, certified nurse-midwives, licensed midwives and other clinical care
providers who will provide services at the center;
(J) the following data concerning the
applicant, the applicant's affiliates, and the managers of the applicant:
(i) any orders of denial, suspension, or
revocation of a center license, a license for any health care facility in any
state, or documentation as a midwife; or any other enforcement action, such as
(but not limited to) court civil or criminal action;
(ii) any orders of denial, suspension, or
revocation of or other enforcement action against a center license, a license
for any health care facility in any state, or documentation as a midwife which
is or was proposed by the licensing agency and the status of the
proposal;
(iii) surrendering a
license before expiration of the license or allowing a license to expire in
lieu of the department proceeding with enforcement action;
(iv) federal or state (any state) criminal
felony arrests or convictions;
(v)
federal or state Medicaid or Medicare sanctions or penalties relating to the
operation of a health care facility;
(vi) operation of a health care facility that
has been decertified in any state under Medicare or Medicaid; or
(vii) debarment, exclusion, or contract
cancellation in any state from Medicare or Medicaid;
(K) for the two-year period preceding the
application date, the following data concerning the applicant, the applicant's
affiliates, and the managers of the applicant:
(i) federal or state (any state) criminal
misdemeanor arrests or convictions;
(ii) federal or state (any state) tax
liens;
(iii) unsatisfied final
judgement(s);
(iv) eviction
involving any property or space used as a center or health care facility in any
state;
(v) injunctive orders from
any court; or
(vi) unresolved final
state or federal Medicare or Medicaid audit exceptions; and
(L) the telephone number, and fax
number (if available) of the center and the telephone number where the
administrator can usually be reached when the center is closed.