Fillable Printable Application For Home Care Licensure: Schedule 1
Fillable Printable Application For Home Care Licensure: Schedule 1
Application For Home Care Licensure: Schedule 1
DOH-1056c (4/15) Page 1 of 5
Personal Identifying Information (Print or Type)
1. Name
☐
Mr. ☐ Mrs. ☐ Ms. ☐ Dr. First Name________________________ Middle Initial______ Last Name________________________________
Street Address __________________________________________________________________________________________________
City_______________________________________________________________ State____________ Zip ________________________
Telephone________________________________________________ Social Security Number___________________________________
Date of Birth ______________________________________________ Place of Birth __________________________________________
2. Formal Education
4. Affirmative Statement of Qualifications
All individuals must provide an affirmative statement explaining why they are qualified to operate the proposed facility/agency. Attach additional pages
as necessary.
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Home Care Licensure and Certification
Application for Home Care Licensure: Schedule 1
Attended
Institution Address From To Degree Date Received
3. Professional Licenses/Certifications Held If Not Applicable, Please Check Here: ☐
Type of Professional License/ Institution Granting
License/Certification Certification License/Certification
(Include Specialty) Number (Mailing Address, Phone & E-mail) Effective Date Expiration Date
DOH-1056c (4/15) Page 2 of 5
5. Employment History for the Past 7 Years
☐ Currently Employed ☐ Currently Unemployed ☐ Retired If retired, please specify date of retirement _________________________________
Start with MOST RECENT employment including employment with the applicant, if applicable. All employment during the last 7 years must be included.
A resume or curriculum vitae (CV) may be substituted for this portion of the application but any additional information requested below and not
contained in such resume or CV must be added. Please photocopy and attach additional sheets, if necessary.
Name of Employer _______________________________________________________________________________________________
Street Address __________________________________________________________________________________________________
City_______________________________________________________________ State____________ Zip ________________________
Dates of Employment From _________________________________________ To ____________________________________________
Position/Title___________________________________________________________________________________________________
Reason for Departure _____________________________________________________________________________________________
Name of Employer _______________________________________________________________________________________________
Street Address __________________________________________________________________________________________________
City_______________________________________________________________ State____________ Zip ________________________
Dates of Employment From _________________________________________ To ____________________________________________
Position/Title___________________________________________________________________________________________________
Reason for Departure _____________________________________________________________________________________________
Name of Employer _______________________________________________________________________________________________
Street Address __________________________________________________________________________________________________
City_______________________________________________________________ State____________ Zip ________________________
Dates of Employment From _________________________________________ To ____________________________________________
Position/Title___________________________________________________________________________________________________
Reason for Departure _____________________________________________________________________________________________
Name of Employer _______________________________________________________________________________________________
Street Address __________________________________________________________________________________________________
City_______________________________________________________________ State____________ Zip ________________________
Dates of Employment From _________________________________________ To ____________________________________________
Position/Title___________________________________________________________________________________________________
Reason for Departure _____________________________________________________________________________________________
Name of Employer _______________________________________________________________________________________________
Street Address __________________________________________________________________________________________________
City_______________________________________________________________ State____________ Zip ________________________
Dates of Employment From _________________________________________ To ____________________________________________
Position/Title___________________________________________________________________________________________________
Reason for Departure _____________________________________________________________________________________________
DOH-1056c (4/15) Page 3 of 5
6. Offices Held or Ownership Interests in Health Facilities
S
tart with MOST RECENT affiliation and include any affiliations as referenced below during the last 7 years. Please photocopy and attach additional
sheets, if necessary.
T
he purpose of this section is to obtain a listing of all affiliations as referenced below with which the owners, board officers, directors, controlling
persons or partners of the proposed organization have been associated in the past 7 years. Affiliation, for the purposes of this section, includes serving
as an owner/operator, voting officer, director or principal stockholder of any health care, adult care, behavioral or mental health facility, program or
agency requiring licensure or certification in New York State. If you have served as an owner/operator, voting officer, director or principal stockholder in
similar facilities or programs outside of New York State, you must also disclose that information. Include facilities for which applications were previously
d
isapproved or withdrawn.
Provide documentation from the appropriate regulatory agency in the states (other than New York State) where you note affiliations, reflecting that the
affiliated facilities, programs and agencies operated in substantial compliance with applicable codes, rules and regulations for the past 7 years (or for the
period of your affiliation, whichever is shorter). Instructions for the out-of-state review, a sample letter of inquiry and a recommended form are provided
in Schedule 2D to assist you in securing this information.
If Not Applicable, Please Check Here: ☐
From__________ To__________ Name of Facility/Agency ________________________________________________________________
Address of Facility/Agency _________________________________________________________________________________________
Type of Facility/Agency__________________________________ Office Held/Nature of Interest ____________________________________
Name of Licensing Agency _______________________________ License/Operating Certificate Number ______________________________
Address of Licensing Agency ________________________________________________________________________________________
From__________ To__________ Name of Facility/Agency ________________________________________________________________
Address of Facility/Agency _________________________________________________________________________________________
Type of Facility/Agency__________________________________ Office Held/Nature of Interest ____________________________________
Name of Licensing Agency _______________________________ License/Operating Certificate Number ______________________________
Address of Licensing Agency ________________________________________________________________________________________
From__________ To__________ Name of Facility/Agency ________________________________________________________________
Address of Facility/Agency _________________________________________________________________________________________
Type of Facility/Agency__________________________________ Office Held/Nature of Interest ____________________________________
Name of Licensing Agency _______________________________ License/Operating Certificate Number ______________________________
Address of Licensing Agency ________________________________________________________________________________________
From__________ To__________ Name of Facility/Agency ________________________________________________________________
Address of Facility/Agency _________________________________________________________________________________________
Type of Facility/Agency__________________________________ Office Held/Nature of Interest ____________________________________
Name of Licensing Agency _______________________________ License/Operating Certificate Number ______________________________
Address of Licensing Agency ________________________________________________________________________________________
DOH-1056c (4/15) Page 4 of 5
C
. Enforcement Actions
During the period of your affiliation listed above, were any of the facilities subject to an enforcement or administrative action taken by the State
regulatory agency due to the facility’s violation of applicable laws and regulations? Attach additional pages as necessary.
☐ Yes ☐ No ☐ Not Applicable
If Yes, please provide the following information:
Nature of Violation
Agency or Body Enforcing Violation (Name & Address)
Has the enforcement or administrative action been resolved? ☐ Yes ☐ No If No, please provide an explanation:
7. Record of Legal Actions
1. Except for minor traffic violations, have you ever been convicted of, or had a sentence imposed for a crime? ☐ Yes ☐ No
2. Are there any criminal actions pending against you? ☐ Yes ☐ No
3. Have you ever been named as a defendant in any civil action, including but not limited to malpractice,
fraud or breach of fiduciary responsibility? ☐ Yes ☐ No
4. Are there now or have there ever been any civil or administrative actions pending against you involving
Medicaid or Medicare issues? ☐ Yes ☐ No
5. Are there now or have there ever been any civil or administrative actions pending against you or any
professional/business entity with which you are affiliated? ☐ Yes ☐ No
6. Are there now or have there ever been any insurance arbitration awards against you or any
professional/business entity with which you are affiliated? ☐ Yes ☐ No
7. Have you ever been involved in a hearing before an official body in relation to the operation of a home
or institution caring for people? ☐ Yes ☐ No
If the answer to any of the above questions is “Yes,” complete the section below. Attach additional sheets if necessary.
Date of Action___________________________________________ Type of Action_______________________________________
Location of Action _________________________________________________________________________________________
Persons and/or Facilities Involved ______________________________________________________________________________
8. Have you ever changed your name (including a maiden name) or used an alias? ☐ Yes ☐ No
If Yes, provide details
9. During the last 7 years, have you been refused a professional, occupational or vocational license by any public or
governmental licensing agency or regulatory authority, or has such a license held by you during such period been
suspended, revoked or otherwise subjected to administrative action? ☐ Yes ☐ No
10. Have you ever been involved in an action or proceeding brought by any public or governmental licensing agency
or regulatory authority for violation of any securities, insurance, workers compensation, taxes, labor law or
regulation or health law or regulation? ☐ Yes ☐ No
DOH-1056c (4/15) Page 5 of 5
11. Have you ever been an officer, trustee, management employee or controlling stockholder of a company, including
the applicant company, where you occupied any such position or served in any such capacity wherein
the company:
a. Became insolvent, declared or was forced to declare bankruptcy or was placed in receivership or conservatorship? ☐ Yes ☐ No
b. Was enjoined from or ordered to cease and desist from violating any securities, insurance or health law or regulation? ☐ Yes ☐ No
c. Was the subject of an investigation by either federal or state law enforcement agencies on issues related to Medicare
or Medicaid fraud? ☐ Yes ☐ No
d. Was required to enter into a Corporate Integrity Agreement as part of a settlement with the Office of Inspector General
of the U.S. Department of Health and Human Services? ☐ Yes ☐ No
e. Suffered the suspension or revocation of its certificate of authority or license to do business in any state? ☐ Yes ☐ No
f. Was denied a certificate of authority or license to do business in any state? ☐ Yes ☐ No
If the answer is Yes to Questions 9, 10, or 11, attach an explanation, including, where applicable, the date, type, and location
of the action and all relevant details.
12. Have you ever been in a position that required a fidelity bond? ☐ Yes ☐ No
Were any claims made against that bond? If Yes, provide details below: ☐ Yes ☐ No
13. Have you ever been denied a fidelity bond or had such fidelity canceled or revoked? ☐ Yes ☐ No
If Yes, provide details below:
8. Confirmatory Statement
I have reviewed the above document and attest that all information is complete, true and accurate.
Please sign in witness of a Notary Public. Please Note: The Notary Public cannot be associated with the application.
Signature _______________________________________________________________________ Date __________________________
Print or Type Name___________________________________________ Title ________________________________________________
STATE OF _______________________________________________, COUNTY OF ___________________________________________
ss:
On the _______________ day of _________________ in the year _________________, before me, the undersigned, a Notary Public in and for
said State, personally appeared ________________________________________________________ personally known to me or proved to
me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she
executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual
acted, executed the instrument.
Signature of Notary Public _________________________________________________________________________________________
Notary Public: State of _____________________
