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How to use or fill out Indiana State Application for License to Operate a Home Health Agency
- Click ‘Get Form’ to open the Indiana State Application for License to Operate a Home Health Agency in our editor.
- Begin with SECTION I, where you will select the type of application. Choose between 'New Facility' or 'Change of Ownership' and provide the anticipated date if applicable.
- In SECTION II, fill out your identifying information. Include the name of your agency, address, contact details, and office hours. Ensure that all fields are completed legibly.
- Proceed to SECTION III for staffing details. Provide names and qualifications of key personnel such as the Administrator and Clinical Supervisor, along with required documentation like resumes and licenses.
- Complete SECTION IV by listing ownership information. Include names and addresses of individuals with significant ownership interests.
- Finally, review all sections for completeness before submitting your application along with the non-refundable fee of $250.
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