Owner Information:

Name:

Title:

Date of Birth:

/ /

SSN:

- -

Gender:

Driver’s Lic / ID Card Number:

State:

Alien Registration Card Number (if applicable):

Home Address:

Cell Phone:

- -

Fax:

- -

Email:

Other Names (previous names used):

Organization Information:

Proposed Organization Legal Name:

Control:

Tax ID:

NPI:

Mailing Address:

Property Address:

Phone:

- -

Fax:

- -

County:

STAFFING:

Name of Administrator:

Hire Date:

/ /

Name of Director of Nursing:

Hire Date:

/ /

Total Number of Home Care Aides:

Electronic Funds Transfer (EFT) information:

Bank Name:

Contact Name:

Bank Address:

Bank Phone:

- -

Fax:

- -

Property Information:

OwnRent/LeaseOther

Property Owner information if Rent/Lease:

Name:

Address:

Phone:

- -

Registered Agent:

Name:

Physical Address:

Mailing Address:

Phone:

- -

Fax:

- -

Medical Director Information:

Name:

Mailing Address:

Phone:

- -

Fax:

- -

NPI:

Medicare #:

Medicaid #:

Credentialing Info

Signal Health Group

Type of Facility:

Owner Information:

Organization Information:

Number of Locations/Satellite offices:

Business Office Hours: (Only days applicable)

STAFFING:

Electronic Funds Transfer (EFT) information:

Property Information:

Registered Agent:

Medical Director Information:

Include these items for Licensing Application: