Ind. IHCP Hospice Services Provider Reference Module, Section 2, Application Process for a Hospice License or Approval

A provider must submit an application for a hospice license, or for approval to operate a hospice program,

on a form prescribed by the IDOH. Any documentation requested on the form must also be submitted.

License or approval to operate a hospice program must be renewed annually. Applicants must include the

license fee with the initial application, and annually thereafter with applications for renewal.

Each application must include the following:

• A single disclosure document, which includes the components outlined in IC 16-25-7, prepared by

the hospice program and updated, as necessary, and used for presentation to each potential patient of

the hospice program

• A copy of the administrator’s or director’s completed criminal history report, pursuant to IC 16-25-6

• A copy of the medical director’s license and resume

• A copy of the patient or family care coordinator’s license and resume

• A copy of the Certificate of Incorporation, signed by the Indiana secretary of state, for all Indiana

corporations; or, if the applicant is an out-of-state corporation, a copy of the Certificate of Authority

signed by the Indiana secretary of state

• A list of each home health aide employed, contracted or used (including as volunteers) by the

applicant at the time of the application, including date of hire, pursuant to IC 16-25-6

• Copies of completed criminal history reports for each home health aide listed by the applicant

• A list of each volunteer used by the provider at the time of the application, including date of hire,

pursuant to IC 16-25-6

• Copies of completed criminal history reports for each volunteer listed by the applicant, pursuant to

IC 16-25-6

• Documentation by the provider of the inquiry to the State Nurse Aide Registry about each home

health aide listed on the application