Department Of Health & Social Services Hospital
State of AlaskaPrint FormDepartment of Health & Social ServicesHospitalLicensure ApplicationApplication for Hospital LicensureGENERAL INSTRUCTIONSA. This application is for both initial and renewal of licensure.B. All items of information on the Application for Hospital Licensure form must be filled in when a hospital makes it's initial and/or renewalapplication for license.C. Prepare the application form in duplicate; send the original to the Health Facilities Licensing & Certification at the address on the lastpage of this application, or e-mail to the e-mail address on the last page.D. Please complete using PDF or print and complete. Print legibly with permanent type ink.E. The applicant should feel free to provide additional information on an attached sheet. This should be done whenever the space on theform is inadequate to give a complete answer.F. This application must be executed and verified by the individual owner or by an authorized officers in the case of a hospital-ownedcorporation, association, or governmental unit or agency.G. There is a license fee. See 7 AAC 12.615 for specific fees due.H. If the hospital's location, ownership changes, or a change in clinical services results in a change of license category, a re-application isalso required.I. Separate applications are required for hospitals operated on separate premises, unless the facilities are functioning under one license,J. Separate applications are required for each individual hospital that is licensed separately, even though ownership is the same.K. Upon renewal, documents provided previously as part of a license application need not be provided again unless there have beenchanges, or as requested by the Department.Additional instruction for completing the application for initial hospital license7 AAC 12.630(b) Governing BodyThis section of the hospital licensing requirements states that the hospital governing body must be formally organized in accordance withwritten by-laws.If this is an initial application, please include a copy of the hospital's governing body by-laws as part of this application.Definitions1. Definition of Hospital. For the purposes of this application, the term hospital means any institution, place, building or agency, public orprivate, whether organized for profit or not, devoted primarily to the maintenance and operations of facilities for the diagnosis, treatmentand/or care of two or more unrelated persons admitted for overnight stay or longer in order to obtain medical, including obstetric,psychiatric and nursing, care of illness, disease, injury, infirmity or deformity. The term hospital includes General Acute Care Hospitals,Rural Primary Care Hospitals, Critical Access Hospitals, Long Term Acute Care Hospitals and Specialized Hospitals.2. Bed complement. Give the present number of beds actually set up for in-patient care, including children's cribs. (Exclude bassinets inmaternity department nurseries, but count those in pediatric departments and in premature nurseries if not located in the maternitydepartment. Exclude labor and recovery beds.)3. Bed capacity. Based only on space designed as patient rooms, whether or not beds are installed; compute the "normal" bed countrequested in the application to be licensed.4. Emergency capacity. Number of beds that can reasonably be added to the bed complement in periods of unusually high occupancy.Include the number of beds that can reasonably be added to the bed capacity in the case of an area wide disaster.Form # HOSPITAL-1001Page 1 of 21
State of AlaskaDepartment of Health & Social ServicesHospitalLicensure ApplicationPursuant to the AS 47.32 Licensing Statute and the regulations of the Department of Health & Social Services Hospital Licensingrequirements (7 AAC 10 and 7 AAC 12) application is herby made for a license to establish, conduct and/or maintain a hospital.BEFORE ATTEMPTING TO COMPLETE THE APPLICATION, PLEASE REVIEW THE HOSPITAL LICENSING RULES AND REGULATIONS. The rulesand regulations can be downloaded from the Alaska Administrative Code, regulations for Hospital licensure.a. Criminal Background Check 7 AAC 10.900 - 990b. General Variance Procedures 7 AAC 10.9500 - 9535c. Inspections and Investigations 7 AAC 10.9600 - 9620d. Hospitals 7 AAC 12.100 - 190e. Specialized Hospitals 7 AAC 12.200 - 225f. General Provisions 7 AAC 12.600 - 990Note: Retain a copy of the application for future reference.IF YOU DO NOT TYPE THE APPLICATION USING ADOBE AND CHOOSE TO COMPLETE THE APPLICATION IN WRITING, BE SURE TO MAKENOTE OF DROP-DOWN BOXES TO PROPERLY COMPLETE THIS APPLICATION.DUE DATE FOR RENEWAL: THE DUE DATE IS 90 DAYS PRIOR TO THE Department Use OnlyEXPIRATION OF YOUR CURRENT LICENSE (AS 47.32.060)License NumberI.Medicaid #TYPE OF LICENSE APPLYING FORII.Choose OneLicense #Medicare #Choose OneLicense Expiration DateNAME AND LOCATION OF HOSPITALExact Legal Name:Mailing Address:CityStateZip CodeStateZip CodePremises Located (If different from above):CityMain Phone Number for Public Use:Administration Phone Number for HFL&C Use:Administration Fax Number for HFL&C Use:E-Mail Address for HFL&C Use:Facility's Fiscal Period (i.e. MONTH/DAY)to(MONTH/DAY)THE DEPARTMENT IS REQUESTING DISCLOSURE OF INFORMATION THAT IS NECESSARY TO ACCOMPLISH THE STATUTORY PURPOSE ASOUTLINED UNDER AS 47.32.040Form # HOSPITAL-1001Page 2 of 21
State of AlaskaDepartment of Health & Social ServicesHospitalLicensure ApplicationIII.OWNERSHIP AND CONTROLA.Type of Control (check one)GOVERNMENTALNON-PROFITPROPRIETARYOther (Explain)B.If Individual or Partnership owned (list all persons who own the Hospital)NameC.Names under which persons in B. do business (other than this Hospital)NameD.AddressBusinessCorporate Ownership(1)Name of Corporation(2)State where Parent Firm or Organization is Incorporated or RegisteredForm # HOSPITAL-1001Page 3 of 21
State of AlaskaDepartment of Health & Social ServicesHospitalLicensure Application(3)List title, name and address of each corporate officerTitleE.NameList names and address of each shareholder holding more than 5 percent of sharesNameF.AddressPercent of SharesFor other than individual ownership, list the name and address of the Alaska registered agent or the person(s)legally authorized to receive service of process for the facility.Name of Registered AgentG.AddressAddressList the names and addresses of all persons OR corporation under contract to manage or operate the facility(Check here if not applicable)Form # HOSPITAL-1001Page 4 of 21
State of AlaskaDepartment of Health & Social ServicesHospitalLicensure ApplicationH.I.Have any of the following been convicted of a felony or of two or more misdemeanors involving moral turpitude inthe last five years? (If yes, attach explanation as Exhibit I.)1.ApplicantYesNo2.Any member of a firm or partnershipYesNo3.Any officer or director of a corporationYesNo4.Administrator or manager of the HospitalYesNoOfficial name of governing body(e.g. BOARD OF TRUSTEES, BOARD OF DIRECTORS, ETC.)PresidentAddressVice PresidentAddressSecretaryAddressJ.If the facility or building is operated on a lease or rental basis, please specify ownershipForm # HOSPITAL-1001Page 5 of 21
State of AlaskaDepartment of Health & Social ServicesHospitalLicensure ressTelephone NumberLicense or Certification Number (if applicable)B.Medical DirectorNameAddressTelephone NumberC.License NumberDirector of NursingNameAddressTelephone NumberD.License NumberBed CapacityNumber of beds for patients (exclude beds in emergency departments, labor and recovery rooms etc.)NUMBER OF BEDSTotal Bed ComplementBed Capacity (number of beds applying for)Emergency CapacityLong Term Care (swing beds / included in total bed capacity)Form # HOSPITAL-1001Page 6 of 21
State of AlaskaDepartment of Health & Social ServicesHospitalLicensure ApplicationBed complement (breakdown of total bed complement by clinical service)BEDSInternal MedicineGeneral SurgicalGynecological and ObstetricsIntensive CareCoronary CareAcute Mental IllnessNeonatal Intensive Care Level IINeonatal Intensive Care Level IIIPediatricsLong Term Acute CareRestorative/RehabilitationOther(please explainTOTALNumber of bassinets in maternity department nurseriesAre any patient beds located in roomsbelow ground level?YesNoIf so, how many?Number of patient care days (exclusive of newborn) rendered in the last calendar or fiscal year?Form # HOSPITAL-1001Page 7 of 21
State of AlaskaDepartment of Health & Social ServicesHospitalLicensure ApplicationV.MEDICAL STAFFIs the medical staff organized with written by-laws, officers, regular meetings, and writtenminutes?YesNo(i.e. both activeandcourtesy groups?)Is the medical staff "closed" (i.e. restricted to active staff only) or open?To what staff group do dentists belong?V.DEPARTMENTS AND SERVICESA.Dietary DepartmentName of person in chargeTitleCurrent Alaska License NumberHas the hospital arranged for the service of a consultant dietition if no full-time or par-time dietician is employed?YesB.NoRadiological DepartmentIs radiological service provided in the hospital?YesNoif not, name hospital, clinic or other facility providing this serviceTypes of services providedDiagnosticRadiologicYesNoRegularNo. of Radiographis UnitsMA rating of each radiographic unitPortableNo. of Radiographis UnitsMA rating of each radiographic unitDentalNo. of Radiographis UnitsMA rating of each radiographic unitOtherNo. of Radiographis UnitsMA rating of each radiographic unitFluoroscopicYesNoRadioactive isotopesYesNoInterventionalYesNoDoes Hospital policy make x-ray film of chest as a routine admission procedure?Form # HOSPITAL-1001YesNoPage 8 of 21
State of AlaskaDepartment of Health & Social ServicesHospitalLicensure ApplicationB.Radiological Department (continued)TherapeuticDeep TherapyYesNoKVP rating of unitIntermediateYesNoKVP rating of unitSuperficialYesNoKVP rating of unitRadium (radon) therapyYesNoRadioactive isotopesYesNoName of Physician in charge of serviceIs he/she Board Certified?Is he/sheFull TimeYesCurrent Alaska License NumberNoPart Time days/weekdays/monthOn CallIf the hospital is not served by a full-time radiologist, or regularly visited by a part-time radiologist, is theradiological service supervised by a member of the medical staff?YesNoNameCurrent Alaska License NumberDoes the hospital radiology department utilize tele-radiology with a radiologist outside the State of Alaska?YesNoIf so, what is the radiologist's name?Current Alaska License NumberC.Clinical Laboratory DepartmentIs the laboratory service provided in the hospital?YesNoCLIA #if not, name hospital, clinic or other facility providing this servicecheck the types of services providedTissue PathologyHistocompatibilityPhotographyBasal MetabolismClinical PathologyBlood bankAutopsyHematologyRadiobioassayDiagnostic nical CytogeneticsOther (specify)Form # HOSPITAL-1001Page 9 of 21
State of AlaskaDepartment of Health & Social ServicesHospitalLicensure ApplicationC.Clinical Laboratory Department (continued)Name of Physician in charge of serviceIs he/she Board Certified?Is he/sheFull TimeYesCurrent Alaska License NumberNoPart Time days/weekdays/monthOn CallIf the hospital is not served by a full-time pathologist, or regularly visited by a part-time pathologist, is theclinical laboratory service supervised by a member of the medical staff?YesNoNameD.Anesthesiology DepartmentYesDoes the hospital provide anesthesia service?NoIf so, name of physician in charge?Is he/she Board Certified?Is he/sheFull TimeYesNoCurrent Alaska License NumberPart Time days/weekdays/monthOn CallIf the hospital does not have an organized anesthesia service, is the anesthesia department supervised by amember of the medical staff?YesWho usually gives anesthesia?M.D.NoNurse AnesthetistIs the person who usually gives anesthesia a hospital employee?E.Other (specify)YesNoOutpatient DepartmentIf the hospital has an organized out-patient department(s), please list the organized clinics conducted(e.g. STD, cancer, pre-natal, orthopedics, etc).Form # HOSPITAL-1001Page 10 of 21
State of AlaskaDepartment of Health & Social ServicesHospitalLicensure ApplicationE.Outpatient Department (continued)If the hospital has no organized out-patient department, please check the types of services provided foroutpatients:F.Laboratory ExaminationEmergency ServicesX-Ray examinationsOutpatient surgical serviceX-Ray or radium therapyOther (specify)Medical DepartmentYesIs there an organized medical department?NoIf so, name of physician in charge?Is he/she Board Certified?Is he/sheG.Full TimeYesCurrent Alaska License NumberNoPart Time days/weekdays/monthOn CallSurgical DepartmentYesIs there an organized surgical department?NoIf so, name of physician in charge?Is he/she Board Certified?Is he/sheH.Full TimeYesCurrent Alaska License NumberNoPart Time days/weekdays/monthOn CallRestorative and Rehabilitation DepartmentYesIs there a restoration and rehabilitation department?Nocheck the types of services providedPhysical TherapyVocational counselingDietaryOccupational TherapyTherapeutic recreationPsychologicalSpeech PathologySocial servicesOther (specify)If so, name of person in charge?Professional specialtyIs he/sheForm # HOSPITAL-1001Current Alaska License NumberFull TimePart Time days/weekdays/monthOn CallPage 11 of 21
State of AlaskaDepartment of Health & Social ServicesHospitalLicensure ApplicationI.Pathology DepartmentIs there an organized pathology department?YesNoIs there a tissue committee of the medical staff?YesNoAre anatomical pathological services provided?YesNoif not, name hospital, clinic or other facility providing this serviceName of physician in charge?Is he/she Board Certified?Is he/sheJ.Full TimeYesNoCurrent Alaska License NumberPart Time days/weekdays/monthOn CallIntensive Care DepartmentIs there an organized intensive care department?YesNoName of person in charge?Is he/she Board Certified?Is he/sheK.Full TimeYesNoCurrent Alaska License NumberPart Time days/weekdays/monthOn CallDental DepartmentYesIs there an organized dental department?NoName of person in charge?Is he/she Board Certified?Is he/sheL.Full TimeYesNoCurrent Alaska License NumberPart Time days/weekdays/monthOn CallSocial Service DepartmentIs there an organized social service department?YesNoName of person in charge?Current Alaska License NumberIs he/sheForm # HOSPITAL-1001Full TimePart Time days/weekdays/monthOn CallPage 12 of 21
State of AlaskaDepartment of Health & Social ServicesHospitalLicensure ApplicationM.Medical Records DepartmentIs there an organized medical records department?YesNoName of person in charge?Is he/sheN.Full TimePart Time days/weekdays/monthOn CallPerinatal DepartmentIs there an organized perinatal department?YesNoName of person in charge?Is he/sheO.Full TimePart Time days/weekdays/monthOn CallEmergency DepartmentIs there an organized emergency department?YesNoName of person in charge?Is he/sheP.Full TimePart Time days/weekdays/monthOn CallRespiratory Therapy DepartmentIs there an organized respiratory therapy department?YesNoName of person in charge?Is he/sheQ.Full TimePart Time days/weekdays/monthOn CallPsychiatric DepartmentIs there an organized psychiatric department?YesNoName of person in charge?Is he/sheR.Full TimePart Time days/weekdays/monthOn CallSubstance Abuse DepartmentIs there an organized substance abuse department?YesNoName of person in charge?Is he/sheForm # HOSPITAL-1001Full TimePart Time days/weekdays/monthOn CallPage 13 of 21
State of AlaskaDepartment of Health & Social ServicesHospitalLicensure ApplicationS.Nuclear Medicine DepartmentIs there an organized nuclear medicine department?YesNoName of person in charge?Is he/sheT.Full TimePart Time days/weekdays/monthOn CallCoronary Care DepartmentIs there an organized coronary care department?YesNoName of person in charge?Is he/sheU.Full TimePart Time days/weekdays/monthOn CallInfection Control DepartmentIs there an organized infection control department?YesNoName of person in charge?Is he/sheV.Full TimePart Time days/weekdays/monthOn CallQuality Improvement DepartmentYesIs there an organized quality improvement department?NoName of person in charge?Is he/sheW.Full TimePart Time days/weekdays/monthOn CallRisk Management DepartmentIs there an organized risk management department?YesNoName of person in charge?Is he/sheForm # HOSPITAL-1001Full TimePart Time days/weekdays/monthOn CallPage 14 of 21
State of AlaskaDepartment of Health & Social ServicesHospitalLicensure ApplicationVI.PERSONNEL BY DEPARTMENTPlease indicate the anticipated total number of full time employees (FTE) employed at the hospital per department. indicate thetotal FTEs in the appropriate category (employed or contractual) for the Department. If this application is for an existing licensedhospital then identify the total FTE on the last day of the most recent pay period. Include only paid employees. If one employeeserves in more than one position, include them in both departments by the estimated fraction of the FTE for each department.DEPARTMENTA.AdministrationB.Business Office and RecordsC.Medical Records and LibraryD.AnesthesiologyEmployed StaffContractualTotal FTEAnesthesiologistNurse AnesthetistE.NursingR.NL.P.N.C.N.A. (Certified Nurse Aide)OthersF.Nursing EducationAdministrativeInstructorsG.X-Ray and RadiologyRadiologistsTechniciansOthersH.Clinical LaboratoryPathologistsTechniciansOthersForm # HOSPITAL-1001Page 15 of 21
State of AlaskaDepartment of Health & Social ServicesHospitalLicensure ApplicationDEPARTMENTI.DietaryEmployed StaffContractualTotal FTESupervisoryCooks and BakersDiet .Social ServicesSocial WorkersSocial Worker AssistantsOthersL.Restorative and Rehabilitative PTOTPTAOTASPOthersM.HousekeepingN.Plant OperationsMaintenance and RepairO.LaundryP.Professional Services(Primary Care)Physicians - SurgeonsResidentsInternsQ.DentalDentistsOthersForm # HOSPITAL-1001Page 16 of 21
State of AlaskaDepartment of Health & Social ServicesHospitalLicensure ApplicationR.Other Departments** If the hospital has other organized departments or other employees, please list and designate the department or the employee'sjob title.DEPARTMENT (or Job Title)SpecialityEmployed StaffContractualTotal FTEForm # HOSPITAL-1001Page 17 of 21
State of AlaskaDepartment of Health & Social ServicesHospitalLicensure ApplicationVII.PHYSICAL PLANTA.Number of beds on each floor or wing.Floor (wing) Name# of BedsFloor (wing) Name# of BedsFloor (wing) Name# of BedsFloor (wing) Name# of BedsFloor (wing) Name# of BedsFloor (wing) Name# of BedsFloor (wing) Name# of BedsFloor (wing) Name# of BedsFloor (wing) Name# of BedsFloor (wing) Name# of BedsFloor (wing) Name# of BedsFloor (wing) Name# of BedsFloor (wing) Name# of BedsFloor (wing) Name# of BedsFloor (wing) Name# of BedsFloor (wing) Name# of BedsFloor (wing) Name# of BedsFloor (wing) Name# of BedsB.Name of person in charge of the physical plantC.New additions and remodeling1.Is the hospital building a new addition or making remodeling changes at the present time?YesNoIf so, please describe2.How will this affect the bed complement?3.Did the hospital require a CON?4.Estimated Cost?Form # HOSPITAL-1001YesNoPage 18 of 21
State of AlaskaDepartment of Health & Social ServicesHospitalLicensure ApplicationVIII.ACCREDITATIONA.Is the facilityfully approved by the Joint Commission or another approved accrediting body?YesB.NoFullHas the facility requested appraisal by an accrediting body?YesIX.ProvisionalNoC.Accrediting bodyD.Date of last Accrediting Body SurveyE.Type of surveyD.Date accreditation expiresINSURANCEA.Does the facility have current Malpractice Insurance?YesB.NoIf yes please provide the following:CompanyAddressExpiration DateX.CRIMINAL BACKGROUND CHECKSA.Does the facility have a system in place for performing cr
This section of the hospital licensing requirements states that the hospital governing body must be formally organized in accordance with written by-laws. If this is an initial application, please include a copy of the hospital's governing body by-laws as part of this application.
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