Section 144-120-2.B - Application Procedure2.B.1. Filing of Application Any person, partnership association or corporation desiring a license to engage in hospice services shall, prior to the commencement of such operation, file an application with the Department. Applications submitted on behalf of a corporation or association shall be made by any two officers thereof or by its administrator. All applicants shall comply with the rules and regulations adopted pursuant to Title 22 MRSA, §2141 et seq. The applicant shall comply with all other applicable Maine Statutes and rules and regulations.
2.B.2. Contents of Application Each application shall contain:
a. The name by which the Hospice Provider is to be legally known and the name under which it shall be doing business;b. A description of all facilities utilized by the Hospice Provider. This will include the address(es), telephone number(s) and name of owner(s) of all buildings utilized by the Hospice Provider,c. A listing of hospice services provided by the Hospice Provider,d. For proprietary corporations: the full name and address of each person, firm or corporation having (directly or indirectly) an ownership interest of 5% or more in the agency,e. For business entities with one owner or business partnerships: the full name and address of the owner or of each partner,f. For not-for-profit organizations: the full name and address of the President of the Board of Directors or appropriate municipal government representative;g. The name, home address, home telephone number and office telephone numbers of the individual designated by the applicant as the program director of the Hospice Provider,h. The name of the Director of Nursing,i. The number of full time equivalent staff10-144 C.M.R. ch. 120, § 2.B