32.02.01.06

.06 Application for a Preliminary Certificate of Registration.

A. Application. An application for a preliminary certificate of registration shall include the information described in this regulation.

B. The names and addresses of the following shall be included:

(1) The facility;

(2) The provider;

(3) Any affiliate, parent, or subsidiary person or business entity; and

(4) The chief executive officer of the provider, the facility, and each affiliate, parent, or subsidiary person or business entity.

C. The application shall describe the organizational structure and management of the provider, including:

(1) If the provider is a corporation or limited liability company, the:

(a) Name of the corporation or limited liability company, and

(b) State in which the corporation is incorporated or the limited liability company is formed;

(2) If the provider is a partnership, the:

(a) Names of the general partners,

(b) State governing the formation of the partnership, and

(c) Name of the primary individual responsible for managing the partnership;

(3) If the provider is an unincorporated association, the:

(a) Names of the members,

(b) State governing the association's activities, and

(c) Name of the primary individual responsible for managing the association;

(4) If the provider is a partnership having a corporation or limited liability company as one or more of its general partners, the:

(a) Names of each corporation or limited liability company,

(b) State in which each corporation is incorporated or the limited liability company is formed, and

(c) Name of the chief executive officer of each;

(5) If the provider is a trust, the:

(a) Name of each trustee,

(b) Names of the owners of beneficial interests in the trust,

(c) State whose laws govern the trust, and

(d) Name of the primary individual responsible for overseeing the trust's activities;

(6) The names and occupations of:

(a) The provider's officers, directors, trustees, managing or general partners, and non-stock corporation members, and

(b) An individual having a 10 percent or greater equity or beneficial interest in the provider;

(7) A description of each financial interest in, or occupation with, the provider of each individual identified under §C(6) of this regulation.

D. Contracts with Related Entities.

(1) If it is anticipated that a business entity will provide to either the facility or the provider goods, premises, or services with a value of $10,000 or more within any fiscal year, and if a person identified in §C(6) of this regulation has a financial interest of 10 percent or more in the business entity, the application shall include:

(a) The name and address of the business entities;

(b) A description of the goods, premises, or services; and

(c) The anticipated yearly costs the facility or provider will incur for the goods, premises, or services.

(2) Section D(1) of this regulation does not require the disclosure of salary, age, or benefit information of employees of the provider.

E. The application shall include a copy of all current documentation concerning the legal organization of the provider, including the corporate charter, bylaws, partnership agreement, articles of association, membership agreement, trust agreement, or similar instruments or agreements.

F. The application shall include certified financial statements of the provider for the three most recent fiscal years for which certified financial statements are obtainable under generally accepted accounting principles. If the provider's fiscal year ended more than 90 days before the date of the filing, then the application shall also include an income statement, which does not need to be certified, that covers a period that begins on the date the fiscal year ended and ends on a date that is within 90 days of the date of the filing.

G. The application shall include a statement of any current or prior affiliation with a religious, charitable, or other nonprofit organization, and the extent, if any, to which the affiliate organization will be responsible for the financial and contractual obligations of the provider.

H. The application shall include a copy of any proposed:

(1) Agreements to be entered into between the provider and subscribers for continuing care; and

(2) Priority admission agreements between the provider and any health care providers.

I. A table of the most current fee structure, including escalator or other automatic adjustment provisions, shall accompany the application.

J. A statement describing the current or proposed use of any insurance program or publicly funded benefit program in the financing of care shall accompany the application.

K. A description of the physical facility shall accompany the application.

L. The form and substance of any advertising campaign, advertisement, or other promotional material for the facility that has not been previously filed with the Department shall be submitted with the application.

M. Any other reasonable and pertinent information that the Department requests in writing shall be submitted with the application.