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|[pic] |Instructions |
|Safety, Oversight and Quality |Nursing Facility License Application |
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|One application form must be submitted for the licensee/owner and another for the operator (e.g., management service). If licensee/owner and operator are the same |
|entity, only one application is required. If the licensee/owner is a different legal entity from the operator/manager entity, two application forms are required. |
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|Complete applications must be received by Aging and People with Disabilities (APD) 45 days prior to date of license renewal or any requested licensing action. |
|Leave no blank boxes. If not applicable, write N/A |
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|Applicant information |
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|Annual license fee: |
| |Licensing fees are determined by the number of licensed beds at the facility |
| |1-15 beds - $1,000; 16-49 - $1,500; 50-99 beds - $2,000; 100-150 beds - $2,500 |
| |151 or more beds - $3,000. Invoice for licensing fee will be sent from DHS accounting, do not submit payment with this application. |
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|Memory Care community endorsement fee: |
| |1-16 beds - $50; 17-50 beds - $75; 51 or more beds - $100 |
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| 1) |Enter the legal name of the applicant/business owner (i.e., legal name of the corporation or the limited liability company). Business names must be |
| |registered with the Oregon Secretary of State Corporate Division. |
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| |If the operator is a different entity than the licensee/owner please complete application for the licensee/owner and for the operator. |
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| 5) |List employer identification number (EIN) as issued by the Internal Revenue Service (IRS) or Social Security Number (SSN). |
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| 6) |Identify name, address phone number of registered agent as recorded with corporation division.* |
| |*Business registry, registered agent information available on-line: |
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| 7) |Applicant ownership, OAR 411-085-0010(4) |
| |Medicare and/or Medicaid – (Certified facilities skip this section and complete the SDS 0466D). Non-Medicare/Medicaid certified facilities must provide |
| |the identity and financial interest of any person, including stockholders, who have an incident of ownership in the applicant representing an interest of|
| |ten percent (10%) or more or ten percent (10%) of a lease agreement for the facility. |
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|Facility information |
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| 8) |Identify name of facility. Facility name must be registered with corporation division either as an assumed business name or a name of corporation. |
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|13) |Name of medical director is required. |
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|14) |Enter total number of licensed nursing facility beds. Do not list more beds than presently capable of operating. If you wish to increase or decrease the |
| |number of beds you must notify the Department of Human Services in writing. |
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|15) |Enter the total number of beds that are ready for immediate use. |
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|16) |Enter the number of beds certified for Medicare. |
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|17) |Check applicable box(es). Check “private pay only” if facility is neither Medicaid nor Medicare certified. |
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|18) |Identify services offered by licensee at this location. Identify number of beds in |
| |each category. |
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|Building information |
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|119-22)Provide building ownership information. |
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|23) |Provide floor plans. For resident rooms, the floor plan will show the room number, location of each bed and room dimensions. Floor plan must identify the|
| |location and purpose of other rooms (e.g., dining, activities, soiled laundry, toilet, etc.). |
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|[pic] |Nursing Facility License Application |
|Safety, Oversight and Quality | |
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|One application form must be submitted for the licensee/owner and another for the operator (e.g., management service). If the licensee/owner are the same entity, |
|only one application is required. If the licensee/owner is a different legal entity from the operator/manager entity, two application forms are required. |
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|Applicant information |
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| 1) |Name of applicant: | | |Facility business owner/licensee |
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| | | | |Facility operator/manager |
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| 2) |Full street address of applicant: (Do not use PO Box – include city/state/ZIP) |
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| 3) |Applicant contact information: |
| |Telephone: | |Fax: | |Email: |
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| 4) |Type of business: | |
| | |Corporation – for profit | |Corporation – not for profit |
| | |Partnership | | | |Individual - sole proprietorship |
| | |Health district | |LLC |
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| 5) |EIN or Social Security number: | |
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| 6) |Name and contact information of registered agent: |
| |(include street address/city/state/zip) |
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| |Telephone: | |Fax: | |Email: |
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|Applicant ownership (Note: Medicaid or Medicare certified facilities skip this section and complete form SDS 0466D. Statement of ownership control.) |
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|Applicant ownership, OAR 411-085-0010(4) |
|Medicare and/or Medicaid –Certified facilities skip section 7 and complete the SDS 0466D. Non-Medicare/Medicaid certified facilities must provide the identity and |
|financial interest of any person, including stockholders, who have an incident of ownership in the applicant representing an interest of ten percent (10%) or more |
|or ten percent (10%) of a lease agreement for the facility. |
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|NOTE: If more than one individual or entity with 10% or greater ownership interest in a non-Medicare/Medicaid facility, please press control and click on the link |
|below. |
|This will provide section 7) for you to fill out and add to this application. Save it to |
|your desktop with a different name and continue to use the form for the rest of your additions. |
| 7) |Name of individual or entity: | |Title: | |Percent of ownership: | |
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| |Street address: (Include city/state/zip code.) | |
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| |SSN or EIN: | |Phone number: |
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|Questions 7-1 – 7-6: Check “Yes” or “No” for each question. For each “Yes”, explain and include specific circumstances (who, what, where and when). |
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|7-1 |Does listed party have a ten percent (10%) incident of ownership in a pharmacy |
| |or other supplier of services/supplies to NF’s? | Yes | No |
| |If yes, explain: |
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|7-2 |Has listed party held an ownership interest in a facility providing services to children, elderly, disabled or ill individuals for which license, |
| |registration or certification was either denied or involuntarily terminated or terminated voluntarily during a state or federal termination process, |
| |during the past five (5) years? |
| |Yes No |
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| |If yes, explain: |
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|7-3 |Has listed party or facility in which party held ownership ever failed to reimburse a state for Medicaid overpayments or civil penalties or failed to |
| |compensate employees or pay workers’ compensation, food supplies, or other costs necessary for facility operation, during the past five (5) years? Yes |
| |No |
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| |If yes, explain: |
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|7-4 |Has the listed party declared bankruptcy within the past five (5) years or held ten percent (10%) incident of ownership in a corporation or business that |
| |declared bankruptcy? Yes No |
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| |If yes, explain: |
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|7-5 |Has party had a nursing facility administrator license or registration revoked? |
| | Yes No |
| |If yes, explain: |
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|7-6 |List all other facilities and business enterprises operated or owned by the applicant currently or previously: |
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|Facility information |
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| 8) |Name of nursing facility: (Use assumed business name.) |
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| 9) |Street address of nursing facility: (Include city/state/ZIP code.) |
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|10) |Facility contact information: |
| |Telephone: | |Fax: | |Email: |
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|11) |Administrator name: | |Administrator license number: |
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| |Administrator email: | |
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|12) |Director of nursing services: | 13) |Medical director: |
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|14) |Total number of licensed beds: | |15) |Total number of set-up beds: | |
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|16) |Number of Medicare beds: | | |
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|17) |Certification status: |
| | |Medicare | Medicaid | Medicaid withdrawal | Private pay only |
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|18) |Type of services offered (Check left side, indicate number of beds on the right.) |
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|Building information |
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|19) |Building owned by applicant? | Yes No |
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|20) |Name of building owner (if owned by a corporation, list name of corporation): |
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|21) |Street address of building owner (include state/city/ZIP): |
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|22) |Phone number of building owner: | |
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|23) |Floor plans attached? | Yes |
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|I, the undersigned, an authorized representative of the applicant, give Aging and People with Disabilities (APD) permission to obtain payment information from the |
|Workers’ Compensation Carrier and any entity from which the applicant leases building, property or business. |
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|24) |Is applicant current on all lease and mortgage payments to the building, property |
| |and business owner(s) or holders of the mortgage? Yes No, see attached, |
| |written explanation. |
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|25) |Is applicant current on all tax payments, utilities (electricity, water, gas, |
| |garbage) and bills for medical supplies and food? Yes No, see attached, |
| |written explanation. |
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|26) |Resident funds surety bond carrier: | |
| |Expiration date: | | |
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|27) |Workers’ Compensation Insurance Company: |
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| |Policy number: | |Expiration date: | |
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|28) |Professional liability insurance company: |
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| |Policy number: | |Expiration date: | |
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|29) |General liability insurance company: |
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| |Policy number: | |Expiration date: | |
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|30) |Auto insurance company: | |
| |Policy number: | |Expiration date: | |
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|31) |Is applicant current on all insurance payments? Yes No, see attached, |
| |written explanation. |
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|READ INSTRUCTIONS. I declare under penalties of perjury that I have examined this application and all the attachments and to the best of my knowledge and belief |
|this information is true, correct and complete. I will notify the department of any changes in this information within thirty (30) days of any such change. I have |
|read, understand and complied with the instructions for this application. |
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|Date | |Printed name | |Title |
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|Signature |
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