Are you looking for a way to stay organized and keep your data in one place? If so, you may find the Hs 215A form useful. This form can help you track employee hours and wages, calculate payroll deductions, and more. In this blog post, we'll give you a brief overview of the Hs 215A form and how to use it.
This basic guide will aid you to ascertain just how long it'll require you to complete hs 215a form, the number of pages it has, and some additional unique specifics of the PDF.
Question | Answer |
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Form Name | Hs 215A Form |
Form Length | 5 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min 15 sec |
Other names | hs 215, hs form, hs215a, ics form 215a |
State of California – Health and Human Services Agency |
California Department of Public Health |
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Licensing and Certification |
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FOR DEPARTMENTAL USE ONLY |
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District: |
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ELMS Facility Number: |
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Proposed name of facility/agency/clinic:
APPLICANT INDIVIDUAL INFORMATION
This form is intended for any individual owning the applicant facility or for any individual involved (now or in the past) with any health or community care facility. Refer to the INSTRUCTION SHEET to see who needs to complete this form.
This HS 215A form needs to be completed as part of an application package plus it needs to be completed for disclosure purposes when changes are reported in officers, directors, purchase of stock, etc., as required by law, even though no change in legal ownership is occurring.
A. Identifying Information
Name
Business address (number, street, apartment/suite number or letter if applicable)
Title in relation to this facility
Date of Birth
City, State, & Zip
Have you applied for ANY license for a health facility or community care facility using any name other than your true full name? If yes, list all other names.
If an Administrator for proposed clinic, list hours that will be spent at the clinic each week. If an Administrator at more than one licensed clinic, list the name of each clinic and the number of hours spent in each licensed clinic per week.
B.Criminal Record
1.Have you ever been convicted of an offense that is still on your record, whether misdemeanor or felony? Yes No
2. Has there been a judgment against you for Medicare or Medicaid |
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professional/technical licensing entity? |
Yes |
No |
If yes to questions 1 or 2 above, please explain and provide dates and conviction information (attach additional pages if
necessary):
C.Professional Licenses/Certificates – This requirement is mandatory for Primary Care Clinics and optional for Health facilities.
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PERIOD HELD |
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ISSUING AGENCY |
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HS 215A (2/08) |
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State of California – Health and Human Services Agency |
California Department of Public Health |
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Licensing and Certification |
D.Employment/Business Summary (for last 10 years). Please list any additional experience
that qualifies you to operate this type of facility. Begin with your most recent job. Attach additional pages if necessary.
Name and address of employer |
Job title |
From:
To:
From:
To:
From:
To:
From:
To:
E. Facility, Agency, Clinic Involvement (in or out of California)
The questions below are for “individuals” and do not pertain to the facility that is applying for licensure.
1.Have you ever been involved with a business entity that operated a health facility or community care facility?
Yes |
No |
If YES, complete Section F (below) and the “Facility Information Sheet” (attached). |
2.Have you ever operated or managed (including management agreements) any of the following facility types?
Yes |
No |
If YES, complete Section F (below) and the “Facility Information Sheet” (attached). |
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Adult Day Health Care Center |
ICF/DD |
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Clinics |
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COMMUNITY CARE FACILITY |
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General Acute Care Hospital |
Intermediate Care Facility |
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Health Facility |
Pediatric Day Health & Respite Care |
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Home Health Agency |
Residential Care Facility for the Elderly |
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Hospice |
Skilled Nursing Facility |
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Other |
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3.Have you ever held a 5 percent or more beneficial ownership interest in any of the facility types above?
Yes |
No If YES, complete Section F (below) and the “Facility Information Sheet” (attached). |
F. Adverse Actions
Have you been affiliated with any facility, either past or present, that has been identified as having one or more of the
following adverse actions? |
Yes |
No |
If YES, check all applicable: |
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Had a final |
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Placed on probation |
Receiver appointed |
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Resolved by settlement |
Revocation action filed |
Revoked (whether stayed or not) |
Suspension |
If yes, please explain (including facility name and address). Attach additional pages if necessary:
I declare under penalty of perjury that the statements on this form and any accompanying attachments are correct to the best of my knowledge.
Signature: |
Date: |
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RELEASE OF INFORMATION STATEMENT
The information provided on this form is mandatory and is necessary for licensure approval. It will be used to determine individual applicant’s or applicant facility’s ability to provide health services. The information is requested by the California Department of Public Health, Licensing and Certification, in accordance with the Health and Safety Code. Failure to provide the information as requested may result in nonissuance of a license or license revocation. The information is considered public information and will be made available to the public upon request. The information shall be included and maintained in the individual facility’s public files located in Licensing and Certification district offices.
HS 215A (2/08) |
2 |
State of California – Health and Human Services Agency |
California Department of Public Health |
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Licensing and Certification |
FACILITY INFORMATION SHEET
You are required to complete the following for each facility (including all facilities in all business entities) with which you have a current relationship or have had a past relationship (going back 3 years). Refer to the INSTRUCTION SHEET.
Facility name:
Facility address (number, street, city):
State:
Zip code:
Type of Facility |
“Type” of Business Entity |
Individual’s “Nature” of Involvement |
Adult Day Health Care Center |
For EACH business entity, identify the name & EIN of the entity: |
Administrator of Clinic, SNF or ICF |
Clinic |
Corporation: |
Agent |
COMMUNITY CARE FACILITY |
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Director |
General Acute Care Hospital |
Individual: |
Licensee |
Health Facility |
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Manager of “parent” organization |
HHA |
LLC: |
Managing employee of a HHA |
Hospice |
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Member |
ICF |
Management Company: |
Officer of corporation |
ICF/DD |
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Owner |
Partnership: |
Partner |
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Sole Proprietorship |
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ICF |
OTHER Business Entity (explain): |
Stockholder |
Residential Care for the Elderly |
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Trustee |
SNF |
Are any of the above Business Entities a “PARENT” organization to the |
OTHER Nature of Involvement (explain): |
OTHER FACILITY TYPE (explain): |
applicant facility? If Yes, explain. |
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Yes |
Dates of involvement: |
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No |
From: |
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To: |
Facility name:
Facility address (number, street, city):
State:
Zip code:
Type of Facility |
“Type” of Business Entity |
Individual’s “Nature” of Involvement |
Adult Day Health Care Center |
For EACH business entity, identify the name & EIN of the entity: |
Administrator of Clinic, SNF or ICF |
Clinic |
Corporation: |
Agent |
COMMUNITY CARE FACILITY |
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Director |
General Acute Care Hospital |
Individual: |
Licensee |
Health Facility |
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Manager of “parent” organization |
HHA |
LLC: |
Managing employee of a HHA |
Hospice |
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Member |
ICF |
Management Company: |
Officer of corporation |
ICF/DD |
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Owner |
Partnership: |
Partner |
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Sole Proprietorship |
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ICF |
OTHER Business Entity (explain): |
Stockholder |
Residential Care for the Elderly |
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Trustee |
SNF |
Are any of the above Business Entities a “PARENT” organization to the |
OTHER Nature of Involvement (explain): |
OTHER FACILITY TYPE (explain): |
applicant facility? If Yes, explain. |
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Yes |
Dates of involvement: |
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No |
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From: |
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To: |
Facility name:
Facility address (number, street, city):
State:
Zip code:
Type of Facility |
“Type” of Business Entity |
Individual’s “Nature” of Involvement |
Adult Day Health Care Center |
For EACH business entity, identify the name & EIN of the entity: |
Administrator of Clinic, SNF or ICF |
Clinic |
Corporation: |
Agent |
COMMUNITY CARE FACILITY |
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Director |
General Acute Care Hospital |
Individual: |
Licensee |
Health Facility |
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Manager of “parent” organization |
HHA |
LLC: |
Managing employee of a HHA |
Hospice |
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Member |
ICF |
Management Company: |
Officer of corporation |
ICF/DD |
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Owner |
Partnership: |
Partner |
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Sole Proprietorship |
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ICF |
OTHER Business Entity (explain): |
Stockholder |
Residential Care for the Elderly |
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Trustee |
SNF |
Are any of the above Business Entities a “PARENT” organization to the |
OTHER Nature of Involvement (explain): |
OTHER FACILITY TYPE (explain): |
applicant facility? If Yes, explain. |
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Yes |
Dates of involvement: |
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No |
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From: |
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To: |
HS 215A (2/08) |
3 |
State of California – Health and Human Services Agency |
California Department of Public Health |
|
Licensing and Certification |
Facility name:
Facility address (number, street, city):
State:
Zip code:
Type of Facility |
“Type” of Business Entity |
Individual’s “Nature” of Involvement |
Adult Day Health Care Center |
For EACH business entity, identify the name & EIN of the entity: |
Administrator of Clinic, SNF or ICF |
Clinic |
Corporation: |
Agent |
COMMUNITY CARE FACILITY |
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Director |
General Acute Care Hospital |
Individual: |
Licensee |
Health Facility |
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Manager of “parent” organization |
HHA |
LLC: |
Managing employee of a HHA |
Hospice |
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Member |
ICF |
Management Company: |
Officer of corporation |
ICF/DD |
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Owner |
Partnership: |
Partner |
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Sole Proprietorship |
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ICF |
OTHER Business Entity (explain): |
Stockholder |
Residential Care for the Elderly |
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Trustee |
SNF |
Are any of the above Business Entities a “PARENT” organization to the |
OTHER Nature of Involvement (explain): |
OTHER FACILITY TYPE (explain): |
applicant facility? If Yes, explain. |
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Yes |
Dates of involvement: |
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No |
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From: |
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To: |
Facility name:
Facility address (number, street, city):
State:
Zip code:
Type of Facility |
“Type” of Business Entity |
Individual’s “Nature” of Involvement |
Adult Day Health Care Center |
For EACH business entity, identify the name & EIN of the entity: |
Administrator of Clinic, SNF or ICF |
Clinic |
Corporation: |
Agent |
COMMUNITY CARE FACILITY |
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Director |
General Acute Care Hospital |
Individual: |
Licensee |
Health Facility |
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Manager of “parent” organization |
HHA |
LLC: |
Managing employee of a HHA |
Hospice |
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Member |
ICF |
Management Company: |
Officer of corporation |
ICF/DD |
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Owner |
Partnership: |
Partner |
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Sole Proprietorship |
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ICF |
OTHER Business Entity (explain): |
Stockholder |
Residential Care for the Elderly |
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Trustee |
SNF |
Are any of the above Business Entities a “PARENT” organization to the |
OTHER Nature of Involvement (explain): |
OTHER FACILITY TYPE (explain): |
applicant facility? If Yes, explain. |
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Yes |
Dates of involvement: |
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No |
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From: |
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To: |
Facility name:
Facility address (number, street, city):
State:
Zip code:
Type of Facility |
“Type” of Business Entity |
Individual’s “Nature” of Involvement |
Adult Day Health Care Center |
For EACH business entity, identify the name & EIN of the entity: |
Administrator of Clinic, SNF or ICF |
Clinic |
Corporation: |
Agent |
COMMUNITY CARE FACILITY |
|
Director |
General Acute Care Hospital |
Individual: |
Licensee |
Health Facility |
|
Manager of “parent” organization |
HHA |
LLC: |
Managing employee of a HHA |
Hospice |
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Member |
ICF |
Management Company: |
Officer of corporation |
ICF/DD |
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Owner |
Partnership: |
Partner |
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Sole Proprietorship |
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ICF |
OTHER Business Entity (explain): |
Stockholder |
Residential Care for the Elderly |
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Trustee |
SNF |
Are any of the above Business Entities a “PARENT” organization to the |
OTHER Nature of Involvement (explain): |
OTHER FACILITY TYPE (explain): |
applicant facility? If Yes, explain. |
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Yes |
Dates of involvement: |
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No |
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From: |
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To: |
HS 215A (2/08) |
4 |
|
State of California – Health and Human Services Agency |
California Department of Public Health |
|
Licensing and Certification |
INSTRUCTIONS FOR HS 215A
The HS 215A must contain an original signature and date. The date of this form should be within the last three months.
This form is intended for the following:
1.Any individual owning an applicant facility;
2.Each agent, each partner, each director, each member, each managing employee of a HHA, each officer of a corporation;
3.Each agent, each partner, each director, each officer, each member or manager of a parent organization of licensee applicant;
4.Each manager, each member of a limited liability company;
5.Administrators;
6.Each person having a beneficial interest of 5 percent or more in the applicant corporation, applicant limited liability company, applicant partnership, applicant management company, applicant facility or private agency; and
7.Each officer and each director of the parent of the management company.
District office and ELMS Number |
To be completed by the California Department of Public Health |
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Proposed name of facility/agency/clinic |
Enter the name of your facility as it appears on your application (HS 200). |
A. IDENTIFYING INFORMATION |
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Name |
Please enter your full legal name. |
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Date of birth |
Day/Month/Year |
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Business Address |
Location of your business; number, street, apartment/suite number or letter if applicable. |
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City |
City where business is located. |
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State |
State where business is located. |
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Zip code |
Zip code where business is located |
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Title in relation to this facility |
Your title in relation to this facility. |
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If an Administrator for proposed clinic, list hours |
Please list hours spent at each clinic per week. If your title is not administrator, please list N/A. |
that will be spent at the clinic each week. If an |
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Administrator at more than one licensed clinic, |
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list the name of each clinic and the number of |
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hours spent in each licensed clinic per week. |
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Have you applied for any license for a health |
Please answer yes or no. If yes, list any other names you have used if you have ever applied for a |
facility or community care facility regardless of |
health facility or community care facility license. |
your role or title using any name other than your |
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true full name? If yes, list all other names. |
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B. CRIMINAL RECORD
Please check appropriate box. If you have checked ‘yes’, please provide dates and conviction information. If not applicable, please enter ‘N/A’.
C. PROFESSIONAL LICENSES/CERTIFICATES
Type |
Type of licenses or certificate that you hold. |
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Period held |
Dates that you held your license. |
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Issuing Agency |
Agency that issued you a license and/or certificate. |
D.EMPLOYMENT/BUSINESS SUMMARY (FOR LAST10 YEARS). Please list any additional experience that qualifies you to operate this type of facility. If self employed, never worked or now retired, indicate the ‘From’ and ‘To’ dates. Begin with your most recent job. Attach additional pages if necessary.
Dates (From/To)
Name and Address of Employer(s)
Job Title
E. FACILITY, AGENCY, CLINIC INVOLVEMENT (IN OR OUT OF CALIFORNIA)
Questions No.
Information Sheet” and complete Section F.
F. ADVERSE ACTIONS
Please check appropriate box. If box is checked yes, please explain and include facility information.
FACILITY INFORMATION SHEET
Facility Name |
Name of Facility that correlates to the checkboxes you have checked as ‘yes’ in Section E. |
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Facility address |
Number and street address of the facility involved. |
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City |
City where facility is located. |
State |
State where facility is located. |
ZIP code |
Zip code where facility is located. |
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Type of Facility |
Check appropriate health facility. |
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“Type” of Business Entity |
Check appropriate business entity and identify if this entity is a “parent” corporation to the applicant |
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facility. |
Individual “Nature” of Involvement |
Check appropriate position held at that facility. |
HS 215A (2/08) |
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