Section  1253.20  Application for Licensure

a)         Entities applying for licensure as a home medical equipment and services provider shall file an application with the Department, on forms provided by the Department.   The application shall include the following:

1)         The name, location (including street, city, state (no post office box)) and telephone number of the applicant;

2)         Certification of insurance from the insurer showing $1,000,000 of commercial general liability insurance, including but not limited to coverage for products liability and professional liability;

3)         All trade or business names used by the applicant;

4)         A list of categories of services provided;

5)         Medicare Identification Number (if applicable);

6)         Name of the person in charge of the day to day operation of the business;

7)         The type of ownership or operation (i.e., partnership, limited liability company, corporation or sole proprietorship).  If a corporation, a copy of the articles of incorporation;

8)         The name of the owner and/or operator of the entity, including:

A)        The name of the person, if a person;

B)        The name of each partner and the name of the partnership, if a partnership;

C)        The name and title of each corporate officer and director, the corporate names, the name of the state where incorporated and the name of the parent company, if any, if a corporation;

D)        The full name of the sole proprietor and the name of the business entity, if a sole proprietorship; or

E)        The full name and title of each member with 5% or more ownership and each manager of a limited liability company and the name of the state where organized and a copy of the articles of organization and the name of any parent company, if any;

9)         The fee set forth in Section 1253.70  of this Part;

10)       Certification, signed by an authorized representative of the entity, indicating that  the business:

A)        maintains a physical facility and  a medical equipment inventory;

B)        maintains records of education, training and experience and annual continuing education for personnel engaged in the delivery, maintenance, repair, cleaning, inventory control and financial management of home medical equipment and services;

C)        maintains records on all patients to whom it provides home medical equipment and services that include any training, education and other information pertinent to the use and maintenance of equipment or the services provided.  Patients' records shall include, but not be limited to, name of patient and address, type of service provided, payer requirements and other pertinent information for the service level or specific product provided.  The provider shall have adequate security measures to maintain confidential records;

D)        establishes and maintains equipment management and personnel policies such as, but not limited to, security operation, tracking and maintenance of equipment, customer service complaints;

E)        complies with  State and federal laws applicable to the type of services provided; and

F)         provides access to emergency services 24 hours a day, 7 days a week for life sustaining home medical equipment and services.

b)         A separate license is required for each facility and only one license will be issued per address where business is conducted.

c)         When the address or name of a facility is changed, the licensee shall be required to notify the Department, obtain a corrected license and pay the required fee set forth in Section 1253.70.

d)         Changes in person in charge of day to day operation shall be submitted to the Department, on forms provided by the Department, within 30 days after such change.

e)         An applicant may be required to appear before the Board to further evaluate the entity's qualifications for licensure.