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:

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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.