10A NCAC 14G .0102 APPLICATION
(a) An application must be submitted to the Department by any health care provider wishing to be exempt from G.S. 90-406.
(b) The application shall include the following information:
(1) the name, address, and telephone number of the health care provider applicant;
(2) the name, address, and telephone number of the manager of the entity to which the health care provider wishes to be able to make referrals;
(3) an explanation of the ownership of the entity to which referrals would be made including the names and ownership interests of all individuals or entities having an investment interest in the entity;
(4) a description of the designated health care services provided or to be provided by the entity;
(5) an analysis of the need for the health care service in the area sufficient to allow the Department to determine that the area is an underserved area for the particular service to be provided; and
(6) documentation of attempts made to obtain alternative financing to develop the entity in which the health care provider has an interest and an explanation as to why any proposed alternative was not reasonable.
(c) Applications shall be sent to the Director's Office, Division of Health Service Regulation, North Carolina Department of Human Resources, 701 Barbour Drive, P.O. Box 29530, Raleigh, N.C. 27626-0530, and shall indicate the purpose of the application.
History Note: Authority G.S. 90-408;
Eff. April 1, 1995.