Arizona Rural Health Clinic Designation Manual - Arizona Center for ...

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Appendix E. Licensing Forms 1. INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR A HEALTH INSTITUTION LICENSE- Page 57 2. INITIAL APPLICATION FOR A HEALTH CARE INSTITUTION LICENSE- Pages 58-60 3. INITIAL APPLICATION CHECKLIST- Page 63 4. RENEWAL APPLICATION FOR A HEALTH CARE INSTITUTION LICENSE- Pages 63-64 5. RENEWAL APPLICATION CHECKLIST- Pages 66 6. OUTPATIENT FACILITY INFORMATION- Pages 67-68 56
Instructions for completing HCI Application PLEASE TYPE OR PRINT IN BLACK INK. Please submit the application, with all required attachments and the required fee. This application will not be complete until all required attachments and fees have been submitted to the Department. If any corrections are made to the application using correction fluid or correction tape, the application will be returned. If you make a mistake filling out the application, put a line through the mistake and your initials. I. HEALTH CARE INSTITUTION INFORMATION Provide all required information. “Tax ID number” means a numeric identifier that a person uses to report financial information to the United States Internal Revenue Services. (If you are using an individual’s Social Security Number, it will be treated as confidential information and redacted from the copy of the application in the facility’s public file.) According to Arizona Revised Statutes, Title 36, Chapter 4, or Arizona Administrative Code, Title 9, Chapter 10, a person may apply for a license as a health care institution class or subclass, which are listed below. Select one of the following classifications and write it on the application. Abortion clinic Adult day health care facility Adult foster care Assisted living center Assisted living home Home health agency Hospice inpatient facility Hospice Hospital Nursing care institution Outpatient surgical center Outpatient treatment center Recovery care center Unclassified Health Care Institution. II. OWNER INFORMATION “Owner” means a person who appoints, elects, or otherwise designates a health care institution’s governing authority. “Proprietary” means an owner or owners. “Non-Proprietary means a leased business, franchise, or in certain instances, a Governmental Agency. III. GOVERNING AUTHORITY “Governing authority” means the individual, agency, group or corporation, appointed, elected or otherwise designated, in which the ultimate responsibility and authority for the conduct of the health care institution are vested. IV. CHIEF ADMINISTRATIVE OFFICER “Chief administrative officer” means the individual implementing a governing authority’s direction in a health care institution. This is the on-site administrator, or the certified manager. V. SIGNATURES According to A.R.S, § 36-422(B) the application must be signed, as follows: (1) If an individual, by the owner of the institution; (2) If a partnership or corporation, by two of the partners or corporate officers; or (3) If a governmental unit, the head of the governmental department having jurisdiction. G:/Instructions for completing HCI ApplicationMEDICAL.doc 06/05/08 57
Page 1 and 2:
Arizona Rural Health Clinic Designa
Page 3 and 4:
Community Environment & Policy 1295
Page 5 and 6: A. Background Information (con’t)
Page 7 and 8: B. Rural Health Clinics in Arizona
Page 9 and 10: C. Number of Rural Health Clinics i
Page 11 and 12: D. Frequently Asked Questions (con
Page 13 and 14: D. Frequently Asked Questions (con
Page 15 and 16: E. Steps to Becoming a Certified Ru
Page 17 and 18: B. Interpretive Guidelines for Rura
Page 29 and 30: D. Preparing for the Certification
Page 37 and 38: 30 Most Common RHC Survey/Certifica
Page 39 and 40: F. RHC Cost Report The Medicare cos
Page 41 and 42: F. RHC Cost Report (con’t) •Wor
Page 43 and 44: F. RHC Cost Report (con’t) 11) Li
Page 45 and 46: G. Important Resources (con’t) -A
Page 47 and 48: Appendix A. Important Contact Infor
Page 49 and 50: Appendix B. Definitions for Rural H
Page 51 and 52: Appendix C. Federal Primary Care HP
Page 53 and 54: Appendix • C. Federal Primary Car
Page 55: Appendix D. Federal MUAs in Arizona
Page 59 and 60: A. PLEASE LIST IN THE SPACE PROVIDE
Page 61 and 62: MEDICAL FACILITIES LICENSING 150 N.
Page 63 and 64: ARIZONA DEPARTMENT OF HEALTH SERVIC
Page 65 and 66: MEDICAL FACILITIES LICENSING 150 N.
Page 67 and 68: http://www.azdhs.gov/als/forms/otcs
Page 69 and 70: Appendix F. Certification Forms 1.
Page 71 and 72: 3. Has successfully completed a for
Page 73 and 74: DEPARTMENT OF HEALTH AND HUMAN SERV
Page 75 and 76: DEPARTMENT OF HEALTH AND HUMAN SERV
Page 77 and 78: According to the Paperwork Reductio
Page 79 and 80: MEDICARE ENROLLMENT APPLICATION INS
Page 81 and 82: 2990 (Cont.) Form CMS 222-92 03-02
Page 83 and 84: RURAL HEALTH CLINIC SURVEY REPORT F
Page 85 and 86: NAME CODE YES NO N/A EXPLANATORY ST
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Arizona Rural Health Clinic Designation Manual - Arizona Center for ...

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