4761:1-5-02 Application form requirements.

(A) The application form for an HME services provider license shall minimally include the following:

(1) The name of the HME services provider (including the name of all legal owners or corporate names used by the applicant) .

(2) The mailing address or corporate mailing address, if different than the physical mailing address of the location of the HME services provider.

(3) The legal name of the HME services provider.

(4) The physical mailing address of the location of the HME services provider.

(5) The 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 .

(6) The name of a person authorized to legally sign on behalf of the HME services provider as a representative agent, if different than the legal owner of the HME services provider, including the last four digits of the person's social security number and date of birth.

(7) The name of a person serving as the manager of the physical location of the HME services provider, if different that the person authorized to legally sign on behalf of the HME services provider, including the last four digits of the person's social security number and date of birth.

(8) The names of shareholders, members, or partners owning five percent interest or more in the HME services provider business, including the last four digits of the social security numbers for each person listed.

(9) The email address for the owner or authorized representative for the HME services provider.

(10) The Ohio medicaid number, federal medicare number, and federal tax identification number for the HME services provider.

(11) A copy of the HME services provider's certificate of product and professional liability insurance from an insurer showing a minimum one million dollars per occurrence, three million dollars aggregate of coverage .

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

(13) A brief description of the HME provided, including square footage of the facility .

(14) A list of the personnel currently employed by the HME service provider who are enaged in the delivery of HME services, including their job titles .

(15) 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.

(16) The HME services provider's compliance with the following requirements:

(a) The HME services provider maintains a facility to adequately store, maintain, lease or sell the HME listed on the application form;

(b) The HME services provider has trained personnel on staff to ensure the HME is maintained, leased, and sold in a manner that is safe to the public;

(c) The HME services provider minimally possesses product and professional liability insurance coverage in the amount of one million dollars per occurence and three million dollars aggregate;

(d) The HME services provider has a filing system established to document all sales and leases of HME, including the maintenance and security of pertinent medical records; and

(e) The HME services provider meets all federal, state, and local rules and regulations regarding the maintenance, storage, and sale of HME listed on the application form.

(17) List of other licenses held by the HME services provider, including, but not limited to, the federal food and drug administration number, federal department of transportation number, and Ohio pharmacy board license number.

(18) The HME services provider's response to the following practice questions:

(a) How long has the HME services provider been renting, selling, delivering, installing, maintaining, replacing or demonstrating HME to Ohio citizens?

(b) Has the HME services provider ever been denied a license, certification, or registration as an HME services provider in any state, for any reason?

(c) Has any license or accreditation associated with the practice of HME ever been revoked, suspended, or conditionally approved?

(d) Has the HME services provider ever violated any provision of the Ohio Revised Code, including providing HME services to Ohio citizens without a license or certificate of registration?

(19) An attestation, signed and dated by the person authorized to legally represent the HME services provider, affirming the thruthfulness of the application and the information contained therein, including compliance with federal, state licensure and regulatory requirements, standards, and compliance with continuing education requirements.

Effective: 11/05/2013
R.C. 119.032 review dates: 07/12/2013 and 03/31/2018
Promulgated Under: 119.03
Statutory Authority: 4752.01(A)(4) , 4752.17(A)(11)
Rule Amplifies: 4752.04 , 4752.17(A)(11)
Prior Effective Dates: 05/23/2005, 03/31/2008