§ 23-17.4-04 — Application for license

North Dakota § 23-17.4-04

• Jurisdiction: North Dakota
• Title 23: Health and Safety
• Ch. 23-17.4: Hospice Programs

Text

An application for issuance or renewal of a hospice program license must be made to the
department upon forms provided by the department. The application must contain information
reasonably required by the department. The application must be accompanied by:
1. The hospice service plan which must include:
a. Identification of the persons administratively responsible for the program, and any
affiliation of the persons with a licensed home health agency, hospital, skilled
nursing home, intermediate care facility, or other health care provider.
b. The estimated average monthly patient census.
c. The proposed geographic area the hospice program will serve.
d. A listing of hospice services provided directly by the hospice, and hospice
services provided indirectly through a contractual agreement.
e. The name and qualifications of persons or entities under contract to provide
indirect hospice services.
f. The name and qualifications of persons providing direct hospice services, with
the exception of volunteers.
g. A description of how the hospice program plans to use volunteers in the provision
of hospice services.
h. A description of the hospice program's recordkeeping system.
2. A financial statement containing information determined to be appropriate by the
department.
3. A uniform license fee determined by the department.