Worker's Comp / PROFIT CORPORATION Church / Affiliated Other Non-Profit PROPRIETARY Individual Corporation / /
Facility
Facility Name Address Form / Hospice Yes No If / Hospice Agency / /
IndustryTerm
transfer services / pharmaceutical hospice services / background applications / nurse practitioner services / basic hospice care services / nursing services / therapeutic services / laboratory services / emotional counseling services / bereavement counseling services / social work services / volunteer services / care or services / dietary counseling services / /
MedicalCondition
pain / terminal illness / /
MedicalTreatment
counseling / /
Organization
Hospice Agency / SERVICE AGENCY / FULL SERVICE AGENCY / Departments Background Check Unit / Department of Health / Medicare / / /
Position
Speech Pathologist & Audiologist / Therapist / program director / corporate officer / Prime Minister / Medical Director Physician / Pastor/Spiritual Counselor / Qualified Person Acting Administrator / Registered Nurse Coordinator / registered nurse / Technical Personnel Yes No Yes No Yes No Yes No Yes No Yes No Administrator / Medical Director Name Address Telephone Number C. License Number Registered Nurse Coordinator / Administrator / Nurse / physician / Licensure Application V. ADMINISTRATION A. Administrator / director of a corporation Yes No / officer / Physician Assistant / manager of the Hospice Yes No If / / Home Health Aide / Dietitian / /
State of Alaska Print Form Department of Health & Social Services