ARIZONA DEPARTMENT OF HEALTH SERVICES
OFFICE OF HEALTH CARE LICENSURE
MEDICAL FACILITIES SECTION
ADDITIONAL INFORMATION NEEDED FOR LICENSING
OF A HOSPICE AGENCY
NAME OF AGENCY
1. If the hospice agency is a subdivision of an institution or other organization (i.e., the home care department of a hospital or the nursing division of a health department), clearly describe the organization, administrative, and supervisory hierarchy within the subdivision and the subdivision's relationship to the larger organization. (An organizational chart may be used).
 
 
 
 
2. Check appropriate space denoting services provided directly by hospice agency and services provided by arrangement with other agencies or individuals. If services are provided through arrangement, specify type of arrangement and by which agency or individual.
SERVICE PROVIDED DIRECTLY BY HOSPICE PROVIDED WITH OTHERS THROUGH ARRANGEMENT
NURSING      
PHYSICAL THERAPY      
SPEECH THERAPY      
OCCUPATIONAL THERAPY      
MEDICAL SOCIAL SERVICE      
H.H. AIDE/HOMEMAKER      
COUNSELING      
VOLUNTEERS      
3.    Check appropriate spaces denoting type of population as served by agency:
       A.   Geographic area
              __________        Citywide
              __________        Countywide
              __________        Other __________________________________(specify)

       B.   Age Group
             __________         All ages
             __________         Selected ages _____________________________(specify)

       C.   Income Group
             __________          Persons able to pay full fee only
             __________          All persons regardless of ability to pay
             __________          Other __________________________________(specify)

4. Name, professional degrees and qualifications of the supervising Nurse.
 
 
 
 
5. If applicable, list name(s) and qualification(s) of individual(s) assigned primary responsibility for physical therapy, speech therapy, occupational therapy, medical social service and any other professional services offered by the agency (other than the Supervising Nurse).
 
 
 
 
 
6. Staffing List - include license or registration number when applicable and check if employee is full time or part time. Please attach additional sheets if necessary.
 
 
 
 
 
7. List names, professional degrees and title of members of Interdisciplinary Group. For those members not employed by hospice agency, list place of employment.