4761:1-6-02 Application form requirements to apply for a certificate of registration.

The application to apply for a certificate of registration shall minimally include the following:

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

(B) Name of the representative agent if it is different form the name of the applicant;

(C) Address of the location of the HME service provider;

(D) Telephone number of the HME service provider, including the number to be contacted in an emergency situation which is monitored twenty-four hours per day, seven days per week;

(E) A list of the HME to be stored, repaired, leased or sold from this business location;

(F) A brief description of the HME provider’s office location, including square footage of the facility;

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

(H) Name of the national accrediting body that issued the accreditation on which the application is based;

(I) The applicant’s accreditation number and the expiration date of the accreditation.

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)(2), 4752.17 (A)(11)

Rule Amplifies: 4752.12 (A), 4752.17 (A) (2)

Prior Effective Dates: 05/23/2005