The application form for an HME services provider certificate of registration shall minimally include the following:
(A) The name of the HME sevices provider (including the name of all legal owners or corporate names used by the applicant).
(B) The mailing address or corporate mailing address, if different than the physical mailing address of the location of the HME services provider.
(C) The legal name of the HME services provider.
(D) The physical mailing address of the location of the HME service provider.
(E) The 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.
(F) 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.
(G) 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.
(H) 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.
(I) The email address for the owner or authorized representative for the HME services provider.
(J) The Ohio medicaid number, federal medicare number, and federal tax identification number for the HME services provider.
(K) A list of the HME to be stored, repaired, leased or sold from this business location.
(L) A brief description of the HME provider's office location, including square footage of the facility.
(M) Name of the national accrediting body that issued the accreditation on which the application is based.
(N) The applicant's accreditation number and the expiration date of the accreditation.
(P) List of other licenses or registrations 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.
(Q) The HME services provider's response to the following practice questions:
(1) How long has the HME services provider been renting, selling, delivering, installing, maintaining, replacing or demonstrating HME to Ohio citizens?
(2) Has the HME services provider ever been denied a license, certification, or registration as an HME services provider in any state, for any reason?
(3) Has any license or accreditation associated with the practice of HME ever been revoked, suspended, or conditionally approved?
(4) 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?
(R) 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.
Cite as Ohio Admin. Code 4761:1-6-02
R.C. 119.032 review dates: 07/12/2013 and 03/31/2018
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, 03/31/2008