​​Additional Instructions

(​​​Each form listed also has instructions on the form)​

B.3 – Organizational Chart – Owner Type

[42 CFR section 485.56]

Submit an organizational chart if the owner is a for profit corporation, nonprofit corporation, limited liability company (LLC), or general partnership. The organizational chart needs to display the following:

• Applicant’s owners, including ownership percentages, Tax IDs/EINs and all directors, board members, corporate officers, LLC, members/managers, and/or partners
  Note: Submit the HS 215A form for each of these individuals
• Parent company of applicant, if applicable, and all of the licensed agencies/facilities it is operating- see B.6

B.4.b – License Revocation (if applicable)

Submit additional information, including all ownership and facility information, date and any final action

[42 CFR sections 420.206 subdivision (a)(3), 455.104, 485.56]

This form must be completed and signed for the following individuals:

• Administrator of the facility
• Owners, directors, board members, corporate officers (Chief Executive Officer, President, Chief Operating Officer, Chief Financial Officer), LLC members/managers, and partners of the parent, grandparent, great grandparent, and etc. organization, if applicable
• Each individual having a beneficial interest of exceeding five percent or more in the applicant organization and/or parent, grandparent, great grandparent, and etc. organization
  

• Page 2, section B — The date of birth is an identifier, as several people may have the same name. This will ensure that each individual is associated with the correct facility or entity
• Page 5, section E — Submit ten years of employment history, indicating the start and end dates of employment, job title, employer name and address. The applicant may submit a resume in lieu of completing section E; however, the resume must contain all required information requested in section E
• Page 7, section F — If answering yes to any question in this section, complete Section H: Facility Information Sheet
  

A resume is required for the Administrator, and Medical Director​

Administrative Organization

Along with the HS 309, the following supporting documents according to organizational type must be submitted:​

Fire Safety Inspection Request

[42 CFR section 485.62(a)(1)]

The STD 850 form is required. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form

• This form is not required for a CHOW unless there has been construction and/or remodeling
• The STD 850 form must be submitted or a similar form from the fire authority that contains equivalent information as the STD 850 form. The HCAI Fire Life & Safety (FLS) Inspection approval does not replace this form

Additional Instructions

(Each form listed also has instructions on the form) ​

Health Insurance Benefits Agreement

Submit two (2) signed forms with “original” signatures:

• Initial Application: Sign the top signature block entitled “Accepted for the Provider of Services By”
  
• CHOW: Sign the bottom signature block entitled “Accepted for the Successor Provider of Services B”

• This letter is issued by Noridian Healthcare Solutions
• The letter should be included with the application packet

Assurance of Compliance

• The Office of Civil Rights (OCR) online portal is: Office for Civil Rights (https://ocrportal.hhs.gov/ocr/​aoc/instruction.jsf)
• Once the online submission is completed, an electronic notification from OCR stating the Assurance of Compliance form was submitted successfully will be received by the applicant
• ​​Submit a copy of this notification