4761:1-5-02 Application form requirements.

(A) The application shall include the following:

(1) Name of applicant (including the name of all trade and business names used by the applicant);

(2) Name of HME service provider's authorized representative agent and other assigned persons representing the applicant, if it is different from the name of the applicant;

(3) Address of the location of the HME services provider;

(4) Telephone number of the HME services provider, including the number to be contacted in an emergency situation, which is monitored twenty-four hours per day, seven days per week if equipment sold, leased or maintained includes life sustaining and/or technologically sophisticated medical equipment;

(5) Certificate of product and professional liability insurance from the insurer showing a minimum one million dollars per occurrence, three million dollars aggregate of coverage;

(6) A list of the HME to be stored, repaired, leased or sold from the HME services provider;

(7) A brief description of the HME provided, including square footage of the facility;

(8) A list of the personnel currently employed at the HME service provider, including their job titles;

(9) List of persons under the employ of the HME service provider having criminal convictions, including the title of the conviction and when and where the conviction took place. This does not include traffic or moving violations.

Effective: 03/31/2008
R.C. 119.032 review dates: 01/11/2008 and 03/31/2013
Promulgated Under: 119.03
Statutory Authority: 4752.17(A)(4), 4752.17(A)(11)
Rule Amplifies: 4752.04, 4752.17(A)(11)
Prior Effective Dates: 05/23/2005