(3) Each application for a health care provider certificate shall be on a form prescribed by the agency. The following information and documents shall be submitted by an applicant and maintained, after certification under this part, by each organization and shall be available for inspection or examination by the agency at the offices of an organization at any time during regular business hours. The agency shall give reasonable notice to an organization prior to any onsite inspection or examination of its records or premises conducted under this section. The agency may require that the following information or documents be submitted with the application:(a) A copy of the articles of incorporation and all amendments to the articles.
(b) A copy of the bylaws, rules and regulations, or similar form of document, if any, regulating the conduct of the affairs of the applicant or organization.
(c) A list of the names, addresses, and official capacities with the applicant or organization of the persons who are to be responsible for the conduct of the affairs of the applicant or organization, including all officers and directors of the corporation. Such persons shall fully disclose to the agency and the directors of the applicant or organization the extent and nature of any contracts or arrangements between them and the applicant or organization, including any possible conflicts of interest.
(d) The name and address of the applicant and the name by which the applicant or organization is to be known.
(e) A statement generally describing the applicant or organization and its operations.
(f) A copy of the form for each group and individual contract, certificate, subscriber handbook, and any other similar documents issued to subscribers.
(g) A statement describing the manner in which health care services shall be regularly available.
(h) A statement that the applicant has an established network of health care providers which is capable of providing the health care services that are to be offered by the organization.
(i) The locations at which health care services shall be regularly available to subscribers.
(j) The type of health care personnel engaged to provide the health care services and the quantity of the personnel of each type.
(k) A statement giving the present and projected number of subscribers to be enrolled yearly for the next 3 years.
(l) A statement indicating the source of emergency services and care on a 24-hour basis.
(m) A statement that the physicians employed by the applicant have been formally organized as a medical staff and that the applicant’s governing body has designated a chief of medical staff.
(n) A statement describing the manner in which the applicant or organization assures the maintenance of a medical records system in accordance with accepted medical records’ standards and practices.
(o) If general anesthesia is to be administered in a facility not licensed by the agency, a copy of architectural plans that meet the requirements for institutional occupancy (NFPA 101 Life Safety Code, current edition as adopted by the State Fire Marshal).
(p) A description of the applicant’s or organization’s internal quality assurance program, including committee structure, as required under s. 641.51. (q) A description and supporting documentation concerning how the applicant or health maintenance organization will comply with internal risk management program requirements under s. 641.55. (r) An explanation of how coverage for emergency services and care is to be effected outside the applicant’s or health maintenance organization’s stated geographic area.
(s) A statement and map describing with reasonable accuracy the specific geographic area to be served.
(t) A nonrefundable application fee of $1,000.
(u) Such additional information as the agency may reasonably require.
