Rule 4729:11-2-03 | Applications.
(A) The following information shall be required on a form supplied by the state board of pharmacy from each person making an application for a HME services provider license or certificate of registration:
(1) The name, full physical business address (not a post office box), and telephone number of the applicant.
(2) All trade, fictitious, or business names used by the applicant (e.g. "doing business as" or "formerly known as").
(3) Addresses, telephone numbers, and the full names of contact persons for all facilities used by the applicant for the storage, handling, and distribution of HME.
(4) The type of ownership or operation (i.e., sole proprietorship, partnership, corporation, or government agency).
(5) The following information for the owner(s) and/or operator(s) of the applicant:
(a) For a partnership:
(i) The full name, business address, social security number, and date of birth of each partner; if the partner is not a natural person each business entity that is a partner having an ownership interest must be disclosed on the application up to and through the entity that is owned by a natural person;
(ii) The name of the partnership; and
(iii) The partnership's federal employer identification number.
(b) For a corporation:
(i) The full name, business address, social security number and date of birth of the corporation's president, vice-president, secretary, treasurer and chief executive officer, or any equivalent position;
(ii) The name or names of the corporation;
(iii) The state of incorporation;
(iv) The corporation's federal employer identification number;
(v) The name of the parent company, if applicable;
(vi) If the corporation is not publicly traded on a major stock exchange, the full name, business address, and social security number of each shareholder owning ten percent or more of the voting stock of the corporation.
(c) For a sole proprietorship:
(i) The full name, business address, social security number, and date of birth of the sole proprietor; and
(ii) If applicable, the federal employer identification number of the business entity.
(6) If the person making application for a certificate of registration, information necessary to verify accreditation authorized pursuant to rule 4729:11-2-04 of the Administrative Code.
(7) If applicable, the Ohio medicaid number, federal medicare number, and federal tax identification number for the applicant.
(8) A copy of the applicant'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.
(9) A list of the HME to be stored, repaired, leased or sold by the applicant.
(10) A brief description of the HME services provided, including square footage of the facility.
(11) A list of the personnel currently employed by the applicant who are engaged in the delivery of HME services, including job titles.
(12) List of other licenses, registrations, or certifications held by the applicant.
(13) Any additional information required on the application as determined by the board.
(14) Any follow-up information as deemed necessary upon the receipt of the application materials.
Supplemental Information