SHARED HEALTH FACILITY REGISTRATION REQUIREMENTS

1. (a) Upon notification by the Department that the facility has been determined to be a shared health facility, the operator of the shared health facility shall:

   1. (1) Sign and submit to the Department two copies of the Shared Health Facility Provider Agreement.
   2. (2) Register the shared health facility with the Department and specify the support and medical services to be provided at the facility.

2. (b) The operator shall apply for initial registration on forms prescribed by the Department and submit the application to the Office of Medical Assistance, Bureau of Provider Relations, Park Penn Building, Post Office Box 8024, Harrisburg, Pennsylvania 17105. At a minimum, the completed application shall contain:

   1. (1) The name of the shared health facility.
   2. (2) The kind of support services to be supplied by the shared health facility and the medical services to be rendered by the providers at the shared health facility.
   3. (3) The location and physical description of the shared health facility.
   4. (4) The name, social security number and residence address of every person, partnership or corporation having a financial interest in the ownership, including leasehold ownership, of the shared health facility and the structure in which the facility is located.
   5. (5) The name, social security number and residence address of every person, partnership or corporation holding a mortgage, lien, leasehold or another security interest in the shared health facility or in equipment located in and used in connection with the shared health facility and a brief description of the lien or security interest.
   6. (6) The name, residence address and professional license number of every practitioner rendering services at the shared health facility.
   7. (7) The name, social security number and residence address of the administrator of the shared health facility.
   8. (8) The name, social security number and residence address of the operators of the shared health facility.

3. (c) The operator shall submit, with the application for registration, copies of all:

   1. (1) Certificates of good standing filed with the Commonwealth Department of State.
   2. (2) Agreements pertaining to the acquisition of the building where the Shared Health Facility is located.
   3. (3) Existing contracts, leases, agreements or service arrangements, and subsequent revisions thereto, with providers within the facility or related to the facility but located outside of the facility.
4. (d) The operator shall forward to the Department, upon request, a description of how the salary or rental amounts were determined between the operator and each provider. The description shall include a projected business volume or other statistics which were used to establish the salary or rental amount.
5. (e) The Department will evaluate the application of the shared health facility for registration and will, within 60 days after receipt of the initial or renewal application, notify the applicant in writing that the shared health facility has either been approved for or denied registration.
6. (f) If the facility is approved, the Department will issue a Registration Certificate to the shared health facility. The certificate is valid for a 1-year period and shall be posted conspicuously in the general reception area of the facility. The Department will also return to the shared health facility one fully executed copy of the Shared Health Facility Agreement.
7. (g) If a shared health facility is denied registration or if the registration and agreement of a shared health facility are cancelled by the Department, providers at the shared health facility will be ineligible to participate in the program at that shared health facility.
8. (h) The operator of a shared health facility shall submit an annual application for renewal of registration of the shared health facility on forms prescribed by the Department at least 60 days prior to the expiration date of the existing registration.