Delaware Health and Social Services Division of Public Health APPLICATION FOR HOSPICE LICENSE AGENCY NAME ________________________________________________________________________ Print AGENCY ADDRESS ________________________________________________________________________ ADDRESS 1 ________________________________________________________________________ ADDRESS 2 ______________________________________ _______________ ________________ CITY STATE ZIP CODE ADMINISTRATOR/CEO ______________________________________________________________________ Print DIRECTOR OF NURSING ____________________________________________________________________ Print ____________________________________________________________________ Delaware Registered Nurse License Number and Expiration Date PHONE NUMBERS ___________________________________ __________________________________ AGENCY PHONE NUMBER AGENCY FAX NUMBER AGENCY TYPE _____ PRIVATE _____ NOT FOR PROFIT PLEASE CHECK ALL THAT APPLY _____ PROPRIETARY ______ OTHER:___________________ GEOGRAPHIC AREA SERVED:_________________________________________________ Print SERVICES PROVIDED: _____ HOME CARE _____ INPATIENT BEDS # BEDS_________ _____ FREE STANDING _____ LEASED BEDS ACCREDITED? _____ YES _____ NO IF YES, NAME OF ACCREDITING ORGANIZATION AND ACCREDITATION EXPIRATION DATE: ________________________________________________________________________________________ Print PLEASE ATTACH THE MOST CURRENT COPY OF THE FOLLOWING: 1. A LIST SHOWING THE NAMES AND ADDRESSES OF EACH OFFICER, DIRECTOR, AND OWNER HAVING TEN (10) PERCENT OR MORE INTEREST IN THE AGENCY. 2. A LIST SHOWING THE NAMES AND ADDRESSES OF THE GOVERNING BODY, IF DIFFERENT FROM THE PRECEDING GROUP. 3. ACCREDITING AGENCY(IES) CERTIFICATE(S) 4. ACCREDITING AGENCY(IES) REPORT(S) 5. FIRE SAFETY REPORT FOR INPATIENT FACILITY 6. OTHER: _________________________________________________________________ ****PLEASE COMPLETE THE TABLE ATTACHED AND RETURN WITH YOUR APPLICATION**** NAME OF PERSON COMPLETING THIS FORM:______________________________________________ Print SIGNATURE:______________________________________________ TITLE:______________________________________________ DATE:_____________________________ CHECKS SHOULD BE MADE PAYABLE TO: DELAWARE DIVISION OF PUBLIC HEALTH INITIAL APPLICATION FEE: $100.00 ANNUAL LICENSURE FEE: $50.00 PLEASE COMPLETE AND RETURN APPLICATION WITH LICENSURE FEE AND ATTACHMENTS TO OFFICE OF HEALTH FACILITIES LICENSING & CERTIFICATION 2055 LIMESTONE ROAD SUITE 200 WILMINGTON DE 19808 Hospice Agency Services and Employee Information Services Provided Does Are the Number Are the Number Are services Total your services of services of provided by number of company provided persons provided by contractors both caregivers provide by employed contractors? providing employees in each these employees in each each and service services? of the service service contractors? agency? Yes No Yes No Yes No Yes No Registered Nurse Licensed Practical Nurse Physical Therapy Nutritional Services Social Services Aide Homemaker Companion Services Durable Medical Equipment Physician Services Ordained Clergy Pastoral Counseling Trained Volunteer Services Other (please list): Doc. No. # 35-05-20/08/02/54 02/05