Virginia Department of Health



0-22860000Virginia Department of HealthOffice of Licensure and CertificationApplication for Home Care Organization Licensure? Initial applicants, complete sections 1–10, 12, and 14–15 ? Renewal applicants, complete sections 1–11 and 15? Organization change of choose one, complete sections 1, 13, and 15, and as may be relevant, complete sections 2, 3, 5, 6, 8, or 9Date: select dateSection 1. Home care organization information – All ApplicantsName of organizationTextTelephone number(###) ###-####Street addressTextFax number(###) ###-####CityTextCountyTextStateTextZip#####Email addressTextMailing address (if different from above)TextCityTextStateTextZip#####Section 2. Ownership (entity or individual that directly owns the home care organization) – All ApplicantsNameTextTelephone number(###) ###-####Federal employer ID no.TextStreet addressTextEmail addressTextCityTextCountyTextStateTextZip#####Fax number(###) ###-####Check business type:For Profit:? Corporation? Partnership? Limited liability company? Sole proprietor? OtherNot for Profit:? Charitable organization? Church? Hospital system? OtherPublic:? County? City? OtherSection 3. Operator (if different from the Owner) – All ApplicantsNameTextTelephone number(###) ###-####Fax number(###) ###-####Street addressTextEmail addressTextCityTextCountyTextStateTextZip#####Section 4. Hours of operation – All ApplicantsIndicate the regular business hours of this organization by listing the opening and closing times of the business office (excluding legal and religious holidays): Time open: #:##a.m. Time closed: #:## p.m. Days of the week: TextSection 5. Geographic service areas – All ApplicantsList each city/county in which the organization expects to provide services.TextTextTextTextTextTextTextTextTextTextSection 6. Branch offices – All ApplicantsWill/Does this organization operate one or more branch offices? ?Yes ? NoIf yes, list address(es) of each branch office below. Attach additional pages as needed:(1) Street addressTextCity/CountyText(2) Street addressTextCity/CountyText(3) Street addressTextCity/CountyTextSection 7. Drop sites – All Applicants Note: Drop sites cannot be used for client contact.Will/does this organization operate one or more drop sites? ?Yes ? NoIf yes, list address(es) of each drop site below. Attach additional pages as needed:(1) Street addressTextCity/CountyText(2) Street addressTextCity/County:Text(3) Street addressTextCity/CountyTextSection 8. Administrative personnel – All ApplicantsJob TitleFull NameStatus(Direct/Contract)Virginia LicenseIf applicableAdministrator (*)Textchoose oneTextAlternate AdministratorTextchoose oneTextNursing Director (*)Textchoose oneTextFinancial ManagerTextchoose oneTextSection 9. Services provided – All ApplicantsState regulation requires that an organization provide at least one of the services listed below by direct employees.ServiceStatus(Direct/Contract)ServiceStatus(Direct/Contract)? Skilled nursing carechoose one? Respiratory therapychoose one? Personal care serviceschoose one? Physical therapychoose one? Pharmaceutical serviceschoose one? Occupational therapychoose one ? Parenteral nutritionchoose one? Speech therapychoose one ? Intravenous therapychoose one? Other: Textchoose oneSection 10. Service personnel – All Applicants Indicate by ‘direct’ or ‘contracted’ the number of staff. ‘Direct’ employees are those for whom the organization pays withholding taxes.Personnel# Direct employees# Contract employeesIf sub-contracted from another organization, indicate nameLicensed nurses######TextCNAs and home attendants######TextRespiratory therapists######TextPhysical therapists & PT assistants######TextOccupational therapists and OT assistants######TextSpeech therapists######TextOther: Text######TextSection 11. Required attachments – Renewal applicants ONLYAttach true, accurate, and complete copies of:? Job description and résumé of the organization’s administrator.? Job description and résumé of the organization’s nursing director.? The organization’s Client’s Rights Policy.? The organization’s current insurance coverage, which includes: ? Malpractice insurance per occurrence consistent with § 8.01-581.15 of the Code of Virginia; ? General liability of at least $1 million comprehensive general liability per occurrence; and ? Third-party crime insurance or a blanket fidelity bond coverage of $50,000 minimum. Proof of insurance or indemnity coverage must specify the organization’s name and street address and be maintained at all times.Section 12. Required attachments – Initial applicants ONLYAttach true, accurate, and complete copies of:? The names and titles of the organization’s governing body.? The meeting minutes of the organization’s governing body that address to initiation/start-up of the organization.? Evidence of the organization’s office occupancy, such as a lease, deed, rental agreement or contract.? The organization’s business plan and working budget showing projected revenue and expenses.? The organization’s emergency preparedness plan.? Job description and résumé of the organization’s administrator.? Job description and résumé of the organization’s nursing director.? The organization’s current insurance coverage, which includes: ? Malpractice insurance per occurrence consistent with § 8.01-581.15 of the Code of Virginia; ? General liability of at least $1 million comprehensive general liability per occurrence; and ? Third-party crime insurance or a blanket fidelity bond coverage of $50,000 minimum. Proof of insurance or indemnity coverage must specify the organization’s name and street address and be maintained at all times.Section 13. Required attachments – Organization change ONLYAs may be relevant, attach true, accurate, and complete copies of:? The organization’s operating agreement (if an LLC) or bylaws (if a corporation), and any amendments to the operating agreement or bylaws. Sole proprietors do not need to attach anything.? Evidence of the organization’s office occupancy, such as a lease, deed, rental agreement or contract.? Job description and résumé of the organization’s administrator.? The organization’s current insurance coverage, which includes: ? Malpractice insurance per occurrence consistent with § 8.01-581.15 of the Code of Virginia; ? General liability of at least $1 million comprehensive general liability per occurrence; and ? Third-party crime insurance or a blanket fidelity bond coverage of $50,000 minimum. Proof of insurance or indemnity coverage must specify the organization’s name and street address and be maintained at all times.Section 14. Medicare and Medicaid – Initial applicants ONLYCheck all that will apply to the organization:? The organization plans to enroll as a Medicare provider. To enroll as a Medicare provider, obtain an application (CMS 855) from the CMS web site at: cms.forms? The organization plans to enroll as a Medicaid provider. To enroll as a Medicaid provider, obtain an application from the Virginia Department of Medical Assistance Services (DMAS) web site at: DMAS.Section 15. Payment and Certification – All ApplicantsFee for licensureFee enclosedInitial licensure fee: $500.00Renewal licensure fee: $500.00Renewal licensure late fee: $50.00License reissuance fee: $250.00Returned check fee: $50.00 ? Check (no starter checks accepted)? Money order? Certified checkMade payable to: VIRGINIA DEPARTMENT OF HEALTH CERTIFICATION? I certify that I am authorized to submit this application and its attachments on behalf of the organization identified in Section 1.? I certify, on behalf of the organization identified in Section 1, that all information submitted in this application and attachments to this application are true, accurate, and complete. I am aware that submitting false information or omitting pertinent or material information in connection with this application or any attachment to this application is cause for denial, suspension, or revocation of license for the organization identified in Section 1.select dateSignatureDateTextTextPrinted NameTitle of SignatoryAn incomplete application shall become inactive six months after it is received by the OLC. Applicants who fail to complete their application within six months of receipt by the OLC must reapply for licensure with a completed application and a new application fee.Return this completed application with attachments and fee no fewer than 60 days prior to the organization’s planned opening date or the expiration of the organization’s license to:Virginia Department of HealthOffice of Licensure and CertificationATTN: Home Care Unit9960 Mayland Drive, Suite 401Henrico, Virginia 23233Questions? Contact the Home Care Unit at: OLC-Inquiries@VDH. or (804) 367-2132. ................
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