ࡱ>    k bjbj 'Ǘ\Ǘ\-8RLLXXXP$tX#k8 < t*,+,+,+t,B-D-$iiiiiii$loZi)-t,t,--i,+,+Hj444-F,+,+i4-i44_c,+ xfz-`,zij0#k`p.pXcc8pc--4-----ii1R---#k----p---------L> : State of Wyoming Department of Health Ph: 307-777-7123 Aging Division Fax: 307-777-7127 Healthcare Licensing and Surveys Web: https://www.health.wyo.gov/aging/hls Hathaway Bldg, Suite 510 Email: wdh-ohls@wyo.gov 2300 Capitol Avenue Cheyenne WY 82002 HOSPITAL LICENSE APPLICATION Fees:Initial (New) Provider or Change in Ownership $1,000Make Payment To: Wyoming Department of Health FOR HLS USE ONLYFee PaidLicense #Appl ApprovedCheck # If we have questions/concerns regarding the information provided on this application, whom should we contact? Contact Persons Name:  FORMTEXT       Email:  FORMTEXT       This is a fillable form. You must tab through the document to advance. Please read the License Application Instructions prior to completing this application. (Licenses will NOT be sent in hard copy but sent electronically to the Email address below.) GENERAL APPLICATION INFORMATION Type of Application: (check one)  FORMCHECKBOX  Initial Application  FORMCHECKBOX  Change in Ownership Effective Date of Change:  FORMTEXT       Accepting assignment of the existing provider agreement  FORMCHECKBOX  Yes  FORMCHECKBOX  No Facility Name: (This is how it will appear on your license. See specific details on the license application instructions.)  FORMTEXT       Physical Facility Full Address: (Main location. Include city, st., zip)  FORMTEXT       Mailing Address: (If different than #3. Include city, st., zip)  FORMTEXT       Fiscal Year End Date:  FORMTEXT       (See specific details on the license application instructions.) Phone:  FORMTEXT       Fax:  FORMTEXT       Email:  FORMTEXT       (See specific details on the license application instructions.) FACILITY NAME:  REF FACNAME \* MERGEFORMAT   PROVIDER DETAILS Are you a Wyoming Medicare/Medicaid Certified Provider?  FORMCHECKBOX  Yes  FORMCHECKBOX  No a. If yes, what is your CMS Certification Number (CCN):  FORMTEXT       (See specific details on the license application instructions.) b. If no, are you planning on applying for Medicare/Medicaid Certification within the next 12 months?  FORMCHECKBOX  Yes  FORMCHECKBOX  No i. If yes, when do you anticipate applying for certification?  FORMTEXT       National Provider Identifier (NPI) number:  FORMTEXT       (See specific details on the license application instructions.) Federal Employer Tax ID (EIN) number:  FORMTEXT       (See specific details on the license application instructions.) Does the facility have in place a documented quality management function to evaluate and improve patient care and services?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Number of licensed beds:  FORMTEXT       a. How many are available for swing beds:  FORMTEXT       b. How many are acute beds:  FORMTEXT       Number of observation beds:  FORMTEXT       Number of operating rooms:  FORMTEXT       Number of endoscopy procedure rooms:  FORMTEXT       Number of cardiac catheterization procedure rooms:  FORMTEXT       Specialized Units: (check as appropriate)  FORMCHECKBOX  Alzheimer Unit  FORMCHECKBOX  PPS Psychiatric Unit  FORMCHECKBOX  PPS Rehabilitation Unit  FORMCHECKBOX  Substance Abuse Unit  FORMCHECKBOX  Special Care Unit  FORMCHECKBOX  Other  FORMTEXT       FACILITY NAME:  REF FACNAME \* MERGEFORMAT   Services Provided: (Check as appropriate.)  FORMCHECKBOX  Alcohol and/or Drug Services  FORMCHECKBOX  Anesthesia Services  FORMCHECKBOX  Audiology  FORMCHECKBOX  Burns Care Unit  FORMCHECKBOX  Cardiac Catheterization Laboratory  FORMCHECKBOX  Cardiac-Thoracic Surgery  FORMCHECKBOX  Chemotherapy Services  FORMCHECKBOX  Chiropractic Services  FORMCHECKBOX  CT Scanner  FORMCHECKBOX  Dental Services  FORMCHECKBOX  Dietetic Services  FORMCHECKBOX  Emergency Department (Dedicated)  FORMCHECKBOX  Extracorporeal Shock Wave Lithotripter  FORMCHECKBOX  Gerontological Specialty Services  FORMCHECKBOX  ICU-Cardiac (non-surgical)  FORMCHECKBOX  ICU-Medical/Surgical  FORMCHECKBOX  ICU-Neonatal  FORMCHECKBOX  ICU-Pediatric  FORMCHECKBOX  ICU-Surgical  FORMCHECKBOX  Laboratory-Clinical  FORMCHECKBOX  Magnetic Resonance Imaging (MRI)  FORMCHECKBOX  Obstetric Services  FORMCHECKBOX  Occupational Therapy Services  FORMCHECKBOX  Operating Rooms  FORMCHECKBOX  Ophthalmic Surgery  FORMCHECKBOX  Optometric Services  FORMCHECKBOX  Organ Transplant Services (Non Medicare-certified)  FORMCHECKBOX  Orthopedic Surgery  FORMCHECKBOX  Outpatient Services  FORMCHECKBOX  Pediatric Surgery  FORMCHECKBOX  Pharmacy  FORMCHECKBOX  Physical Therapy Services  FORMCHECKBOX  Positron Emission Tomography Scan  FORMCHECKBOX  Post-Operative Recovery Rooms  FORMCHECKBOX  Psychiatric Services-Emergency  FORMCHECKBOX  Psychiatric-Child/Adolescent  FORMCHECKBOX  Psychiatric-Forensic  FORMCHECKBOX  Psychiatric-Geriatric  FORMCHECKBOX  Psychiatric-Adult Inpatient  FORMCHECKBOX  Psychiatric-Outpatient  FORMCHECKBOX  Radiology Services-Diagnostic  FORMCHECKBOX  Radiology Services-Therapeutic  FORMCHECKBOX  Reconstructive Surgery  FORMCHECKBOX  Respiratory Care Services  FORMCHECKBOX  Rehab Services Inpatient  FORMCHECKBOX  Rehab Service Outpatient  FORMCHECKBOX  Renal Dialysis (Acute Inpatient)  FORMCHECKBOX  Social Services  FORMCHECKBOX  Speech Pathology Services  FORMCHECKBOX  Surgical Services-Inpatient  FORMCHECKBOX  Surgical Services-Outpatient  FORMCHECKBOX  Swing Bed Services  FORMCHECKBOX  Trauma Center (Designated)  FORMCHECKBOX  Transplant Center (Medicare Certified)  FORMCHECKBOX  Urgent Care Center Services 20. Do you currently have deemed status with one of the nationally recognized accrediting organizations below? (See specific details on the license application instructions.)  FORMCHECKBOX  Yes  FORMCHECKBOX  No a. If yes, what approved accrediting organization do you belong to: (Check one)  FORMCHECKBOX  TJC  FORMCHECKBOX  HFAP  FORMCHECKBOX  CIHQ  FORMCHECKBOX  DNV GL i. Date of Last Accrediting Survey (Attach a copy.):  FORMTEXT       b. If no, do plan on obtaining  deemed status within the next 12 months?  FORMCHECKBOX  Yes  FORMCHECKBOX  No i. If yes, approximately when do you plan on applying for  deemed status?  FORMTEXT       FACILITY NAME:  REF FACNAME \* MERGEFORMAT   In accordance with W.S. 35-2-910(c), does the Hospital provide for the review of professional practices in the hospital for the purpose of reducing morbidity and mortality and for the improvement of the care of patients in the hospital? This review shall include but not be limited to: (a)The quality and necessity of the care provided to patients as rendered in the hospital; (b)The prevention of complications and deaths occurring in the hospital; (c)The review of medical treatments and diagnostic and surgical procedures in order to ensure safe and adequate treatment of patients in the hospital; and (d)The evaluation of medical and health care services and the qualifications and professional competence of persons performing or seeking to perform those services. The review shall be performed according to the decision of a hospital's governing board by: (a)A peer review committee appointed by the organized medical staff of the hospital; (b)A state, local or specialty medical society; or (c)Any other organization of physicians established pursuant to state or federal law and engaged by the hospital for the purposes of W.S. 35-2-910(c).  FORMCHECKBOX  Yes  FORMCHECKBOX  No PERSONNEL 22. Name/Title of person in charge of facility, agency, or clinic:  FORMTEXT       (See specific details on the license application instructions.) 23. Name of Administrator:  FORMTEXT       24. Name of Director of Nursing:  FORMTEXT       a. Professional License Type:  FORMTEXT       b. Professional License Number:  FORMTEXT       Name of Registered Dietitian:  FORMTEXT       a. Wyoming License Number:  FORMTEXT       b. On Staff  FORMCHECKBOX  Under Contract  FORMCHECKBOX  26. Name of Certified Dietary Manager:  FORMTEXT       a. Date Completed Course:  FORMTEXT       or b. If currently enrolled in course, anticipated completion date:  FORMTEXT       27. Name of Medical Director (if applicable):  FORMTEXT       a. Professional License Type:  FORMTEXT       b. Professional License Number:  FORMTEXT       FACILITY NAME:  REF FACNAME \* MERGEFORMAT   28. Name of Maintenance Director (if applicable):  FORMTEXT       a. Contact phone number:  FORMTEXT       LOCATIONS/BUILDINGS (You must attach a readable and clear floor. See specific details on the license application instructions.) 29. Main Building Location a. Property Ownership:  FORMCHECKBOX  Own  FORMCHECKBOX  Rent  FORMCHECKBOX  Lease b. Physical Address: (Include city.)  FORMTEXT       c. Services at this location:  FORMTEXT       d. Date services began at this location:  FORMTEXT       e. Is there a current construction or remodel project going on at this location?  FORMCHECKBOX  Yes  FORMCHECKBOX  No f. If yes, list HLS project numbers:  FORMTEXT       Number  % - 5 = Q d e m n ѵyn[H[%ho3hX`B*CJOJQJaJph%ho3hqB*CJOJQJaJphh/+ hqOJQJh/+ hq5OJQJ#h_hjF5CJOJPJQJaJhjF5CJOJPJQJaJh'u5CJOJPJQJaJh75CJOJPJQJaJhX`5OJPJQJ\h'u5OJPJQJ\"hIh'u5@OJPJQJ\hIh'u5OJPJQJ\:[> S e n d$If]gd)d$If]gdJ.$d^a$gdJ. 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FORMTEXT       a. For each of these locations an Attestation Form must be attached to this application. The Attestation Form can be found with the license application instructions. Please attach a copy of your Critical Access Hospital PTAN report. This report will identify all locations enrolled under your hospitals CCN as filed with your CMS 855 application. This report can be obtained from the PECOS system. See specific details on the license application instructions.) OWNER 32. Ownership type: (check one) (See specific details on the license application instructions.) a.  FORMCHECKBOX  Sole Proprietor/Individual b.  FORMCHECKBOX  Partnership c.  FORMCHECKBOX  Profit Corporation d.  FORMCHECKBOX  Nonprofit Corporation e.  FORMCHECKBOX  Limited Liability Company f.  FORMCHECKBOX  Governmental:  FORMCHECKBOX  City  FORMCHECKBOX  County  FORMCHECKBOX Hospital District  FORMCHECKBOX  State g. Other:  FORMTEXT       FACILITY NAME:  REF FACNAME \* MERGEFORMAT   33. Ownership Name:  FORMTEXT       34. Mailing Address:  FORMTEXT       35. Phone:  FORMTEXT       36. Contact Person:  FORMTEXT       37. Contact Person s Email:  FORMTEXT       38. List all officers in the ownership and titles below: or  FORMCHECKBOX  List attached. (This is the Pres, VP, etc. or Board Members; not the CEO, CFO, etc. See specific details on the license application instructions.) a.  FORMTEXT       b.  FORMTEXT       c.  FORMTEXT       d.  FORMTEXT       e.  FORMTEXT       39. Has the owner ever had a license to operate a healthcare facility or agency providing healthcare services in this or any other state denied, suspended, revoked or otherwise terminated for cause?  FORMCHECKBOX  Yes  FORMCHECKBOX  No a. If yes, explain:  FORMTEXT       OPERATOR 40. Is the facility operated or managed by a business entity other than the owner section above?  FORMCHECKBOX  Yes  FORMCHECKBOX  No a. If yes, Operating Entity Name:  FORMTEXT       b. Mailing Address:  FORMTEXT       c. Phone:  FORMTEXT       d. Contact Person s Name:  FORMTEXT       e. Contact Person s Email:  FORMTEXT       41. Has the operator ever had a license to operate a healthcare facility or agency providing healthcare services in this or any other state denied, suspended, revoked or otherwise terminated for cause?  FORMCHECKBOX Yes  FORMCHECKBOX  No a. If yes, explain:  FORMTEXT       42. Did you read and understand the healthcare facility licensure requirements (W.S. 35-2-901 and 902 et seq) outlined in the license application instructions?  FORMCHECKBOX  Yes  FORMCHECKBOX  No FACILITY NAME:  REF FACNAME \* MERGEFORMAT   SIGNATURE Wyoming Statutes requires signature by two (2) officers of the organization, or a signature of all managing agents. If signed by managing agents, copies must be attached of company documents indicating the individuals signing are managing agents for the company. I have read the contents of this application. My signature legally binds the facility s agreement to abide by the rules promulgated by the Stat of Wyoming for this category of healthcare facility and do hereby state the information provided on this application is true to the best of my knowledge and belief. The facility further understands the facility is responsible for admitting and retaining only those persons who qualify for this category of healthcare facility as defined in the applicable rule and facility policies and procedures. The facility agrees to allow authorized representative of the Wyoming Department of Health, upon presentation of proper identification, to request and/or enter the facility at any time without a warrant, any facility records and documentation as necessary to ascertain compliance with State licensing laws and rules promulgated by the Wyoming Department of Health. Application must have original signatures of two officers as listed in the ownership section above. In most cases, a CEO, CFO, Administrator, or Director signature will not be accepted. Signature #1__________________________________________________________________________________ Printed Name:  FORMTEXT       Title:  FORMTEXT       Date:  FORMTEXT       Signature #2___________________________________________________________________________________ Printed Name:  FORMTEXT       Title:  FORMTEXT       Date:  FORMTEXT           Rev. 07/01/2021 Page  PAGE 1 of  NUMPAGES 7 Rev. 07/01/2021 Hospital License Application Page  PAGE 7 of  NUMPAGES 7 Rev. 07/01/2021 Hospice Facility License Application Page  PAGE 2 of  NUMPAGES 6 Rev. 07/01/2021 Hospice Facility License Application Page  PAGE 6 of  NUMPAGES 6 Rev. 07/01/2021 Hospital License Application Page  PAGE 6 of  NUMPAGES 7 &,.8<>@BDH\h óufWfO@jhW1phMUOJQJUhMUOJQJhX`hCJOJQJaJhX`h CJOJQJaJhW1ph OJQJhW1ph97OJQJh./OJQJhW3SOJQJhMOJQJhJ.OJQJhOJQJhJ.h/(5CJOJQJaJhM5CJOJQJaJ hmh7CJOJPJQJaJh7CJOJPJQJaJ h8`h7CJOJPJQJaJ,.>@ jlXZ "d^`gd./hhd^h`hgdMUd^`gdH.02jrt &(*X`b~ "r`#jBhW1phMUOJQJU#jBhW1phMUOJQJU#jAhW1phMUOJQJU#j6AhW1phMUOJQJU#j@hW1phMUOJQJU#jN@hW1phMUOJQJUhMUOJQJjhW1phMUOJQJU#j?hW1phMUOJQJUhW1phMUOJQJ%"$24PRTdf "唆pXPHh./OJQJhJ.OJQJ/jh_$hMU>*OJPJQJUmHnHu*jbDh_$hMU>*OJPJQJUh_$hMU>*OJPJQJ$jh_$hMU>*OJPJQJUhMUOJQJ#jChW1phMUOJQJU#jzChW1phMUOJQJU#jChW1phMUOJQJUhW1phMUOJQJjhW1phMUOJQJU"BDº²{eMB7hW1phaOJQJhW1ph'(OJQJ/jh_$h>*OJPJQJUmHnHu*jDh_$h>*OJPJQJUh_$h>*OJPJQJ$jh_$h>*OJPJQJUhW1ph+OJQJhW1ph97OJQJhJ.OJQJhW3SOJQJh./OJQJ h./>*OJPJQJmHnHuh./>*OJPJQJjh./>*OJPJQJUh./OJPJQJ8:xz,.FHvx d^gdMUd^`gdH &(*468:<>BLPRfhjtvxz|~ݿxݿbWhW1phU!OJQJ*jEh_$h>*OJPJQJUhW1phaOJQJ/jh_$h>*OJPJQJUmHnHu*jJEh_$h>*OJPJQJUh_$h>*OJPJQJ$jh_$h>*OJPJQJUhW1ph97OJQJhW1ph+OJQJhJ.OJQJh./OJQJhW3SOJQJ(*,̾̐}u}j̾T̐*jFh_$h>*OJPJQJUhW1ph,OJQJh./OJQJhJ.OJQJhW1phaOJQJ/jh_$h>*OJPJQJUmHnHu*j2Fh_$h>*OJPJQJUh_$h>*OJPJQJ$jh_$h>*OJPJQJUhW1ph+OJQJhW1ph97OJQJhW1phDOJQJ,.26Z| ژ~o`oUB$jh_$h>*OJPJQJUhW1phwFOJQJhX`huCJOJQJaJhX`h CJOJQJaJhX`hmCJOJQJaJhW1phmOJQJhW1ph,OJQJ#jGhW1phMOJQJUhW1phMOJQJjhW1phMOJQJUhW1phCOJQJhW1ph97OJQJhJ.OJQJh./OJQJhW1ph COJQJ 468BDFHLNPdfhrtvx|~ȰȥqȰȥ[Ȱȥ*jvHh_$h>*OJPJQJU*jHh_$h>*OJPJQJUhW1phwFOJQJhW1ph97OJQJhJ.OJQJhW1phOJQJ/jh_$h>*OJPJQJUmHnHu$jh_$h>*OJPJQJU*jGh_$h>*OJPJQJUh_$h>*OJPJQJ ׿״׈r׿g_WLA9hc1OJQJhW1phKOJQJhW1ph<OJQJhcc%OJQJh./OJQJhW1ph1EOJQJ*j^Ih_$h>*OJPJQJUh_$h>*OJPJQJhW1phwFOJQJhW1ph97OJQJhJ.OJQJhW1phOJQJ/jh_$h>*OJPJQJUmHnHu$jh_$h>*OJPJQJU*jHh_$h>*OJPJQJU246@BDFHꬤxbJBhMOJQJ/jh_$h>*OJPJQJUmHnHu*jJh_$h>*OJPJQJUh_$h>*OJPJQJ$jh_$h>*OJPJQJUhW1ph<OJQJhJ.OJQJhW1phhfxOJQJ#jFJhW1phMOJQJU#jIhW1phMOJQJUjhW1phMOJQJUhW1phMOJQJhW1phKOJQJDFH\^&@B~<>.0d^`gdMU d^gdMUd^`gdHHX^`bftv$&(*FHJLRTVļĞĈufuTfIu>uhW1phKOJQJhW1ph2OJQJ#j.KhW1phMOJQJUjhW1phMOJQJUhW1phMOJQJhc1OJQJhW1ph OJQJhW1phuOJQJhOJQJhW1phCOJQJhW1ph#)OJQJhMUOJQJhW1ph97OJQJhJ.OJQJh./OJQJhW3SOJQJhMOJQJhJ.hM5CJOJQJaJVXtvx~.02<>@HRVXlȵ~fȵPfȵ*jLh_$h>*OJPJQJU/jh_$h>*OJPJQJUmHnHu*jLh_$h>*OJPJQJUh_$h>*OJPJQJ$jh_$h>*OJPJQJUhW1ph+OJQJhJ.OJQJhW1ph97OJQJ#jKhW1phMOJQJUhW1phMOJQJjhW1phMOJQJUlnpz|~*,.8:<>@BF׿״ד}׿״דg׿\TLh./OJQJhW3SOJQJhW1phOJQJ*jMh_$h>*OJPJQJU*jrMh_$h>*OJPJQJUh_$h>*OJPJQJhW1ph+OJQJhJ.OJQJhW1ph97OJQJ/jh_$h>*OJPJQJUmHnHu$jh_$h>*OJPJQJU*jLh_$h>*OJPJQJUF0"$&,.06TXZnpr߶ߤseOs*jBOh_$h>*OJPJQJUh_$h>*OJPJQJ$jh_$h>*OJPJQJUhW1ph+OJQJhMUOJQJhW1phyk^OJQJ#jNhW1phMOJQJU#jZNhW1phMOJQJUjhW1phMOJQJUhc1OJQJhW1phMOJQJhW1phhfxOJQJhW1ph<OJQJr|~ "$&ygyyUyJ?hW1ph>OJQJhW1phOJQJ#j*PhW1phMOJQJU#jOhW1phMOJQJUhW1phMOJQJjhW1phMOJQJUhc1OJQJhW1phmOJQJhW1ph<OJQJh./OJQJhW3SOJQJhJ.OJQJhW1phaOJQJ$jh_$h>*OJPJQJU/jh_$h>*OJPJQJUmHnHu"$&(&JL N|*.d hd^hgdJ. hd^hgdJ.d^`gdH&(HJ*FRV>@,JLӲvvvvvnh}POJQJhW1ph.4aOJQJhW1phlOJQJhW1ph+OJQJhW1pha|tOJQJh}Phv5CJOJQJaJh}Ph/(5CJOJQJaJ h5>*OJPJQJmHnHuh5>*OJPJQJjh5>*OJPJQJUh5OJPJQJh<3OJQJ+L^`d "&(<>@JLX\^rtvĶĈĶrĈĶ\ĈQhW1ph+uOJQJ*jQh_$h>*OJPJQJU*jQh_$h>*OJPJQJU/jh_$h>*OJPJQJUmHnHu*jPh_$h>*OJPJQJUh_$h>*OJPJQJ$jh_$h>*OJPJQJUhW1ph+OJQJhW1ph OJQJh}POJQJhW1ph.4aOJQJ|&(*,02̾̐̾z̐̾d̐YQMQhDjhDUhW1phca;OJQJ*jRh_$h>*OJPJQJU*jnRh_$h>*OJPJQJU/jh_$h>*OJPJQJUmHnHu*jQh_$h>*OJPJQJUh_$h>*OJPJQJ$jh_$h>*OJPJQJUhW1ph+OJQJhW1ph OJQJhW1ph.4aOJQJ.046:<@B  H$)gdW  H$)gd:zi  H$)gd<3 |)d:gdl; 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