Department of Health and Hospitals
Facility Name: _________________________________________________________________
Address: _____________________________________________________________________
_____________________________________________________________________
Telephone No.: (___) ________________
Facility Email: ________________________________________________________________
Fiscal Intermediary: ____________________________________________________________
Fiscal Year End Date: ___________
Administrator: _________________________________________________________________
Administrator Address:___________________________________________________________
Administrator Phone: ____________________________________________________________
Medical Director: _______________________________________________________________
Days of Operation: ___________________ Hours of Operation: _____________
Fire Marshal Approval Date: __/__/__ Health Approval Date: __/__/__
This application is hereby tendered for consideration. All statements are accurate to the best of my knowledge. I also understand that all statements are subject to verification.
__________________________________ ____________________
Signature of Applicant Date
___________________________________
Print Applicant Name
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