STATE OF MICHIGAN
LARA Use Only
|Date Received |HOSPICE LICENSURE APPLICATION |
| |APPENDIX A |
| |(Attach/Submit Appendix with BHCS-HFD-100 Form) |
|Facility Number | |
| |
|(Hospice Agency/Residence) |
| |
|(Address) |
| | | |
|(City) |(State) |(ZIP Code) |
|1. Hospice Residence |
|For a new residence license, the applicant complies with MCL 333.21413(2)? Yes No |
|Number of residence beds: |This application is to increase the number of hospice residence beds? Yes No |
|The hospice residence provides: |
|home care (MCL 333.21401(1)(a)) inpatient care (MCL333.21401(1)(c)) both |
|2. Hospice Services |
|Services |Service provided by: |Contractor Agency Name |
| |Licensee |Contractor | |
|Medical R 325.13302 | | | |
|Physicians’ Assistants R 325.13303 | | | |
|Nursing R 325.13304 | | | |
|Bereavement & Spiritual R 325.13305 | | | |
|Volunteer R 325.13306 | | | |
|Social Work Rl325.13307 | | | |
|3. Disclosure of Ownership Interests |
|R 325.13206(1) states that an applicant shall include the following information for a license: |
|(a) Name, address, principal occupation, and official position of all persons with ownership interest in the hospice or hospice residence. |
|(b) Name, address, principal occupation, and official position of each trustee for a voluntary nonprofit corporation. |
|(c) If located on or in leased real estate, name of lessor and any direct or indirect interest in the applicant. |
|(2) The department will accept reports filed with the securities and exchange commission in place of subrule (1), if the report(s) contain the |
|information required. |
| |
|The above information has been provided as an attachment: Yes No |
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