Ohio Administrative Code › Title 4729:11 - HME Services › Chapter 4729:11-2 - HME Services Provider › Section 4729:11-2-03 - Applications

Current through all regulations passed and filed through July 1, 2024
(A)
								The following information shall be required on a form
			 supplied by the state board of pharmacy from each person making an application
			 for a HME services provider license or certificate of registration:
(1)
									The name, full
			 physical business address (not a post office box), and telephone number of the
			 applicant.
(2)
									All trade, fictitious, or business names used by the
			 applicant (e.g. "doing business as" or "formerly known as").
(3)
									Addresses,
			 telephone numbers, and the full names of contact persons for all facilities
			 used by the applicant for the storage, handling, and distribution of
			 HME.
(4)
									The type of ownership or operation (i.e., sole
			 proprietorship, partnership, corporation, or government
			 agency).
(5)
									The following information for the owner(s) and/or
			 operator(s) of the applicant:
(a)
										For a partnership:
(i)
											The full name,
			 business address, social security number, and date of birth of each partner; if
			 the partner is not a natural person each business entity that is a partner
			 having an ownership interest must be disclosed on the application up to and
			 through the entity that is owned by a natural person;
(ii)
											The name of the
			 partnership; and
(iii)
											The partnership's federal employer identification
			 number.
(b)
										For a corporation:
(i)
											The full name,
			 business address, social security number and date of birth of the corporation's
			 president, vice-president, secretary, treasurer and chief executive officer, or
			 any equivalent position;
(ii)
											The name or names of the corporation;
(iii)
											The state of
			 incorporation;
(iv)
											The corporation's federal employer identification
			 number;
(v)
											The name of the parent company, if
			 applicable;
(vi)
											If the corporation is not publicly traded on a major
			 stock exchange, the full name, business address, and social security number of
			 each shareholder owning ten percent or more of the voting stock of the
			 corporation.
(c)
										For a sole proprietorship:
(i)
											The full name,
			 business address, social security number, and date of birth of the sole
			 proprietor; and
(ii)
											If applicable, the federal employer identification
			 number of the business entity.
(6)
									If the person
			 making application for a certificate of registration, information necessary to
			 verify accreditation authorized pursuant to rule 4729:11-2-04 of  the Administrative Code.
(7)
									If applicable, the Ohio medicaid number, federal
			 medicare number, and federal tax identification number for the
			 applicant.
(8)
									A copy of the applicant's certificate of product and
			 professional liability insurance from an insurer showing a minimum one million
			 dollars per occurrence, three million dollars aggregate of
			 coverage.
(9)
									A list of the HME to be stored, repaired, leased or
			 sold by the applicant.
(10)
									A brief description of the HME services provided,
			 including square footage of the facility.
(11)
									A list of the
			 personnel currently employed by the applicant who are engaged in the delivery
			 of HME services, including job titles.
(12)
									List of other
			 licenses, registrations, or certifications held by the
			 applicant.
(13)
									Any additional information required on the application
			 as determined by the board.
(14)
									Any follow-up
			 information as deemed necessary upon the receipt of the application
			 materials.