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Attachment E-1 Managment Company Information Only FOR SNFs Or ICFs HS 200 - California
| Attachment E-1 Managment Company Information Only FOR SNFs Or ICFs Form. This is a California form and can be used in Licensing And Certification Department Of Health And Human Services Statewide . |
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ATTACHMENT E-1 MANAGEMENT COMPANY INFORMATION ONLY FOR SNF's or ICF's 1. Submit a copy of the Management Agreement with this application. Name of management company: Address (number & street): City, State, & Zip: Name of facility to be managed: Address (number & street): City, State, & Zip: EIN: EIN: 2. Provide the following information for each individual having a 5 percent or more interest in the management company. Submit an attachment for additional names that includes all of the required information listed below. (1) Individual's name: Address (number & street): City, State, & Zip: (2) Individual's name: Address (number & street): City, State, & Zip: (3) Individual's name: Address (number & street): City, State, & Zip: (4) Individual's name: Address (number & street): City, State, & Zip: % Owner: % Owner: % Owner: % Owner: 3. Provide a list of all facilities, agencies, or clinics with which you have entered into a management agreement. Submit an attachment for additional facility, agency, or clinic names that includes all of the required information listed below. (1) Facility, agency, or clinic name: Address (number & street): City, State, & Zip: (2) Facility, agency, or clinic name: Address (number & street): City, State, & Zip: (3) Facility, agency, or clinic name: Address (number & street): City, State, & Zip: (4) Facility, agency, or clinic name: Address (number & street): City, State, & Zip: Dates of involvement: Dates of involvement: Dates of involvement: Dates of involvement: HS 200 (07/06) 5 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS SNF or ICF Management Company Application: See Attachment E-1 below. Type or print clearly. Return original and maintain a copy for your records. The Licensee's name must be consistent throughout all documents submitted. Submit all supplemental paperwork requested to complete your application. Do not leave items blank. If not applicable, mark N/A. A. APPLICATION INFORMATION 1. Type of application: select items a, b, c, or d. If b is selected, provide effective date of change in number 2. If c is selected, complete Sections C1-5; F, and Attachment E-1. If d is selected you must select an option in number 4 -- "Type of Change." 2. Provide actual date applicant took charge of the financial management of facility. This date is used to show effective date of the ownership change for certification purposes only. 3. Amount of fee enclosed: enter the amount of money enclosed with this application. If no fee is required, enter "N/A". (Refer to fee schedule for appropriate fee requirements.) 4. Type of change: check all that apply. 5. Type of facility, agency, or clinic: select the appropriate category. 6. (a) Check "yes" if requesting certification for Medicare. ICF/DD, ICF/DD-N, ICF/DD-H facilities and primary care clinics that are not certified as rural health clinics are not eligible for Medicare. (b) If "yes" to item 6(a), provide name of fiscal intermediary under item 6(b). 7. Check "yes" if requesting participation in Medi-Cal (Medicaid). 8. (a) Current facility bed capacity: enter the total number of persons for whom care can currently be provided in any 24-hour period. This figure must agree with the "Certificate of Occupancy". (b) Proposed facility bed capacity: enter the proposed total number of persons for whom care will be provided in any 24-hour period. 9. Enter age range of persons to receive/receiving care. 10. Enter days and hours of facility operation. 11. Enter date construction is to begin, and date construction is to be completed (not applicable for ICF/DD, ICF/DD-N, ICF/DD-H facilities). Submit a copy of the form "Construction Advisory Board" (form OSH-FDD 377(11/97)) if OSHPD has approved construction. Submit a copy of the above form to the local district office prior to the survey if OSHPD has not yet approved construction. B. LICENSEE INFORMATION 1. Licensee name: enter the full legal organization name (LLC, partnership, and corporation) or individual(s) responsible for the facility/agency. If "Inc." is included in your legal name, it must appear in the name. Individuals enter first, middle, and last name. Husband and wife, if joint applicants, must both be listed. NOTE: All individuals including owners, partners, principal officers of corporations/LLCs, members, managers, and administrators (clinics only) must complete "Applicant Individual Information" (HS 215A). 2. 3. Enter the federal employer's tax ID number. Owner Type: select one of the options and then: Submit an organizational chart, for items b, c, d, or e showing entity, persons, facilities, and tax EIN numbers. Submit a copy of the Internal Revenue Service and Franchise Tax Board letters of determination of nonprofit status, if item c, "nonprofit corporation" is selected, and the facility is a primary care Clinic. HS 200 (07/06) 6 American LegalNet, Inc. www.FormsWorkflow.com 4. 5. 6. Licensee address: enter address of legal organization (LLC, corporation, partnership) or individual(s) responsible for the facility, agency, or clinic. Provide phone number with area code, fax number, and e-mail address. Other Facilities: (a) Identify all other facilities, agencies, or clinics the licensee (LLC, corporation, partnership, individual) has been involved in, both in and outside of California. Submit an attachment, if needed, for additional entities, which includes the facility, agency or clinic type (including "affiliate" clinics), name, address, nature of involvement, and dates of involvement. This attachment must include all of the required information listed. Submit an attachment, if needed, for any entity identified in number 5a, which has had a license revocation action filed, license placed on probation, suspended, or revoked (whether stayed or not) or, for SNFs and ICFs, resolved by settlement, receiver appointed, or has a final Medi-Cal decertification action taken. Include all ownership and facility information, dates, and any final action. Subsidiary: check "yes" if the licensee is a subsidiary of another organization and complete the information requested. Submit a detailed organizational chart, including parent and all subsidiary information, and federal tax ID numbers. C. FACILITY, AGENCY, OR CLINIC INFORMATION 1. Management Agreement: (a) Check "yes" if the facility, agency, or clinic is going to be operated under a management contract/agreement, between the proposed owner and a management company. Proceed to Section "E" (below). (b)
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