Primary Care Clinic
Form HS 215A
The HS 215A is required for:
- Directors, board members, corporate officers, and partners of a partnership of the applicant organization
- Directors, board members, corporate officers, and partners of the parent company.
- Administrator, include the number of hours, per week, spent in each facility where employed. Note: The administrator designee must be designated in writing and placed in the facility’s administrative files.
Please complete all items on the HS 215A and provide all requested supplemental documents. Do not leave any items blank. If a question does not apply, respond with “Not Applicable” or “N.A.”. The following table provides further details for the section/item that require special instruction.
FACILITY INFORMATION SHEET
If applicable, each individual must complete and submit the “Facility Information Sheet” for each facility and/or agency with which he/she have a current or past relationship within the last 3 years. The following must be completed for each facility and/or agency:
- Facility Name
- Facility Address, City, State, Zip Code
- Type of Facility
- Type of Business Entity
- Are any of the Business Entities a “Parent” company to the applicant facility
- Individual’s “Nature” of Involvement
- Dates of Involvement