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Fillable Printable Form 51053

Fillable Printable Form 51053

Form 51053

Form 51053

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SUPPLEMENTARY INFORMATION TO FEDERAL APPLICATION
END STAGE RENAL DISEASE (ESRD) FACILITY
State Form 51053 (R3/4-07)
Indiana State Department of Health-Division of Acute Care
Division of Acute Care Use Only
Date Received
(month, day, year) __________________ Date Approved (month, day, year) __________________
All questions on this application must be answered completely in print or type script. Supporting documentation must be
attached to the application. Complete all sections on this application. An incomplete application or illegible application will
be returned without processing.
Please Type or Print Legibly
SECTION I - TYPE OF APPLICATON
Application(check appropriate item)
Change of Ownership (A ntici p ated date of Sale/Purchase /Lea se)_____ ______ _______ New Facility Other
Submit a dated and signed copy of the bill of sale, lease or other document of transfer
Medicare and MedicaidMedicare
SECTION II - IDENTIFYING INFORMATION
A. Practice Location (name of facility d/b/a of direct owner)
If the d/b/a name is different from the direct owner’s name submit a “Certificate of Assumed Business Name” document from the State of Indiana,
Office of the Secretary of State (SOS) listing the corporation name (direct owner) and doing business name (d/b/a). The d/b/a should be registered with
the State of Indiana Office of the Secretary of State.
Name of facility
Street address (number and street) P.O. Box
City County ZIP Code
Facility’s office hours (i.e. 8:00 a.m. – 4:00 p.m.)Telephone number
( )
Fax number
( )
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
E-mail address Web address
B. Mailing Address (if different from practice location)
Street address (number and street)
P.O. Box
City
State ZIP Code
C. Ownership Information (direct owner of the facility-d/b/a)
List the owner/entity as registered with the State of Indiana Office of Secretary of State (SOS) and appears on the SOS document. Submit document
from the SOS along with a document from the Internal Revenue Service (IRS) that reflects the corporation name, d/b/a if applicable and EIN number.
Owner/entity
Street address (number and street)
P.O. Box
City State ZIP Code
Telephone number
( )
Fax number
( )
EIN number Fiscal year end date (mm/dd)
Reset Form
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D. Provider Based
Is this facility hospital/provider based? (Is yes, list provider based Medicare number)
Hospital Based?
Yes No SNF/NF Based? Yes No
If yes, submit the documentation requested on the enclosed Provider Based Determination letter.
SECTION III - TYPE OF SERVICES
Services Provided (check all services that ap p ly and where services are provided)
Hemodialysis: Where are the services provided?
Facility SNF/NF Residential/Assisted Living Home
Peritoneal Dialysis: Where are the services provided?
Facility SNF/NF Residential/Assisted Living Home
Transplantation:
Yes No
Home Training:
Hemodialysis: Where are the services provided? Facility SNF/NF Residential/Assisted Living Home
Peritoneal Dialysis: Where are the services provided? Facility SNF/NF Residential/Assisted Living Home
Home Support:
Hemodialysis: Where are the services provided? Facility SNF/ NF Residential/Assisted Living Home
Peritoneal Dialysis: Where are the services provided? Facility SNF/NF Residential/Assisted Living Home
If you provide home training/home support services complete the enclosed Request to Provide HomeHemodialysis Training and Home
Hemodialysis Services Questionnaire and/or the CAPD/CCPD Services Questionnaire required by Centers of Medicare and Medicaid Services
(CMS) for Medicare certification.
Do you provide hemodialysis at your facility to patients ?
on vents:
Yes No bed or cart bound:Yes No morbid obesity:Yes No
Number of Stations: __________Total Stations ________Hemodialysis + ________Hemodialysis Training
PLEASE NOTE: Indiana does not have reciprocal agreements to cross state lines to conduct surveys. Hemodialysis in NF outside of Indiana will not be
approved for an Indiana ESRD facility.
SECTION IV – STAFFING
All positions are required.
The resumes submitted to the department must reflect the qualifications listed below or the application will be rejected.
A. Administrator/Director/CEO (as defined in 42 CFR 405.2136)
The Chief executive officer (CEO) as defined at 405.2102 is a person who: (1) Holds at least baccalaureate degree or is equivalent and has at least one
year of experience in an ESRD unit; or (2) is a registered nurse or physician director as defined in the regulations; or (3) as of September 1, 1976, has
demonstrated capability by acting for at least two years as a chief executive officer in a dialysis unit or transplantation unit.
Name (enter full name)
Submit a copy of applicable licenses (billfold) from the Indiana Professional Licensing Agency with expiration date, resume that reflects name of
employers, month/year of employment and must include the above qualifications on the resume. The Administrator/Director/CEO may also serve as
the Physician Director or the Nurse Director if qualifications are met.
B. Alternate Administrator/Director/CEO(as defined in 42 CFR 405.2136)
The Chief executive officer (CEO) as defined at 405.2102 is a person who: (1) Holds at least baccalaureate degree or is equivalent and has at least one
year of experience in an ESRD unit; or (2) is a registered nurse or physician director as defined in the regulations; or (3) as of September 1, 1976, has
demonstrated capability by acting for at least two years as a chief executive officer in a dialysis unit or transplantation unit.
Name (enter full name)
Submit a copy of applicable licenses (billfold) from the Indiana Professional Licensing Agency with expiration date, resume that reflects name of
employers, month/year of employment and mustinclude the above qualifications on the resume. The Administrator/Director/CEO may also serve as
the Physician Director or the Nurse Director if qualifications are met.
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C. Physician Director (as defined in CFR 405.2102, 405.2161)
The director of the facility must be a qualified physician director and is defined by §405.2102 as a physician who:
1. Is board-eligible or board-certified in internal medicine or pediatrics by a professional board, and has had at least 12 months of experience or
training in the care of patients at ESRD facilities; or
2. During the 5 year period prior to September 1, 1976, served for at least 12 months as director of a dialysis or transplantation program; or
3. In those areas where a physician who meets the definition in paragraph (1) or (2) here is not available to direct a participating dialysis facility,
another physician may direct the facility, subject to the approval of the Secretary.
Name (enter full name)
Submit a copy of physician’s license (billfold size) from the Indiana Professional Licensing Agency with expiration date, resume that reflects name of
employers, month/year of employment and must include the above qualifications on the resume. The Physician Director may also serve as
Administrator/Director/CEO if qualifications are met.
D. Nurse Director (as defined in CFR 405.2102 & 405.2162(a))
The nurse director of the facility must be a nurse responsible for nursing service and is defined in §405.2102 as a person who is licensed as a register
nurse by the State in which practicing, and
1. Has at least 12 months of experience in clinical nursing, and an additional 6 months of experience in nursing care of the patient with
permanent kidney failure or undergoing kidney transplantation, including training in and experience with the dialysis process; or
2. Has 18 months of experience in nursing care of the patient on maintenance dialysis, or in nursing care of the patient with a kidney transplant,
including training in and experience with the dialysis process;
3. If the nurse responsible for nursing service is in charge of self-care dialysis training, at least 3 months of the total required ESRD experience is
in training patients in self care.
“Full time” means employed 40 hours/week by the facility or for the number of hours the facility is open, whichever is less. One nurse could be
employed full time at two facilities if one was open Monday/Wednesday/Friday and the second was open Tuesday/Thursday/Saturday. A single RN
could not be considered full time by 3 or more facilities.
Name (enter full name)
Submit a copy of Registered Nurse license (billfold size) from the Indiana Professional Licensing Agency with expiration date, resume that reflects name
of employers, month/year of employment and must include the above qualifications on the resume. The Nurse Director may also serve as
Administrator/Director/CEO if qualifications are met.
SECTION V - OWNERSHIP OF APPLICANT ENTITY
A. Ownership and Controlling Interest(as defined in CFR 405.2136)
List names and addresses of individuals or organizations who have or hold direct or indirect ownership of 10% or more in the facility
Name Business Address (street address/city/state/zip) EIN Number
B. Ownership Information (Officers/Directors/Partners)(as defined in CFR 405.2136 )
List all individuals (persons) associated with the applicant entity and indicate the individual’s title (i.e. officer, director, member, partner,
president, vice president, secretary, etc). If the applicant is a partnership, list the name and title of each partner or the name and title of all
individuals associated with each entity that forms the partnership. If the applicant is a Limited Liability Company, list the name and title for
all individuals associated with each member entity that forms the Limited Liability Company. (use additional sheet if necessary)
Name Title
Business Address (street address/city/state/ZIP Code)
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C. Owed and/or Managed by a Multi-Facility Organization
Is this facility owned and/or managed by a multi-facilit y organization?
Yes No (If yes, name and address of parent organization)
Name Address (street address/cit y/state/zip )
D. Type of Change in Ownership (applicable for change of ownership only – do not complete if initial application)
Asset Purchase Agreement Assignment of Interest Lease
Merger New Partnership Sale
Termination of Lease Transfer of Asset AgreementOther ______________________
E. Type of Entity(Complete for initial and change of ownership applications)
For Profit NonProfit Government
Individual Church Related State
Partnership Individual County
Corporation Partnership City
Limited Liability Company Corporation City/County
Sole Proprietorship Limited Liability Company Hospital District
Other (specify)_____________________________ Other (specify)_____________________ Federal
_____________________________________________ _____________________________________
Other (specify)________________
_____________________________________________ _____________________________________ ________________________________
If a Limited Partnership, submit a cop y of the “Applic ation For Registration” and Certificate of Registration” signed by the State of
Indiana, Office of the Secretary of State.
If a Corporation, submit a copy of the “Articles of Incorporation” and “Certificate of Incorporation” signe d by the State of Indiana,
Office of the Secretary of State. If a foreign Corporation, submit a copy of the “Certificate to do Business in the State of Indiana”
signed by the State of Indiana, Office of the Secretary of State.
If a Limited Liability Company, submit a copy of the “Articles of Organization” and the “Certificate of Organization” signe d by the
State of Indiana, Office of the Secretary of State.
If the “doing business as” (dba) name is different from the corporation’s (direct owner) name submit “Certificate of Assumed
Business Name” signed by the State of Indiana, Office of the Secretary of State that list the corporation and d/b/a name.
Submit documentation from the Internal Revenue Service that reflects your corporation name, d/b/a if applicable a nd EIN number.
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SECTION VII - DOCUMENTATION TO BE SUBMITTED WITH INITIAL APPLICATION
A letter outlining the details of what the facility is applying for and the services the facility will be providing.
A copy of the “Articles of Incorporation” or “Certificate of Assumed Business Name” document from the State of Indiana Office of
the Secretary of State.
A document from the Internal Revenue Services (IRS) that reflects the corporatio n name and EIN number
Copies of applicable current Indiana licenses (billfold size) from the Indiana Professional Licensing Agency and resumes that
reflect qualifications of position.
SECTION VIII - APPLICANT’S SIGNATURE OR SIGNATURE OF AUTHORIZED AGENT SHOULD APPEAR BELOW
Signature of authorized representative
Title Date (month, day, year)
Notify the Indiana Sate Department of Health (ISDH) in writing of any changes in your staff or services. In yo ur corres pondenc e incl ude
the facility name, complete ad dress, CMS Ce rtification Number (CCN) and facility number.
Submit initial application, change of ownership application or changes to:
PHNSS-Program Director
Indiana State Department of Healt h
Acute Care Division
2 North Meridian Street, Section 4A 07
Indianapolis, IN 46204
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