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INSPECTION INFORMATION FOR APPLICANTS SEEKING TO OBTAIN A (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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INSPECTION INFORMATION FOR APPLICANTS
SEEKING TO OBTAIN A
HEALTH CARE SERVICE FIRM REGISTRATION
After submission of your application and supporting documents, you will be contacted by an Investigator
from the Division of Consumer Affairs to schedule an appointment for an inspection of your business
location prior to a registration being issued.
At this inspection of your business, you will need to provide the following information or documents to
the Investigator:
The location where you will be securing your business records for clients and
employees
A copy of the Registered Nursing License issued to your Health Care Practitioner
Supervisor (“Director of Nursing”)
A copy of the Application For Employment of any registered nurse employed by
your business (not required if your business is nurse-owned)
A copy of the Certificate of Malpractice Insurance (if applicable) for your Director of
Nursing
If you are operating your business from your home, the Investigator will need to verify that:
You have checked with your municipality to determine what, if any, Permits are
required for you to operate a business in your home and have secured any required
Permits
You maintain a separate entrance/exit for the public to access your office that does
not allow visitors to walk through your home’s private residential space
If you are operating your business at a “shared” services office facility, the Investigator will need to
inspect:
Your file cabinets for securing all client and employee documents
Your rental agreement or lease for “shared” office space
During this inspection, the Investigator will also take the time to review the “Best Practices”; the Laws &
Regulations governing Health Care Service Firms; and the Health Care Professional Responsibility and
Reporting Act with you.
PLEASE NOTE: PHOTOGRAPHS OF YOUR OFFICE LOCATION INSIDE AND OUT WILL BE TAKEN
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Ofce of Consumer Protection
Regulated Business Section
124 Halsey Street, 7th Floor, P.O. Box 45028
Newark, NJ 07101
(973) 504-6370
Instructions to Apply for Registration as a Health Care Services Firm
(N.J.A.C. 13:45B-13.3)
In order to expedite the issuance of registrations, the following instructions are being provided for those who wish to apply
for registration as a health care services rm.
1. Provide the name of the business. This name must match the name on the corporate, alternate name and trade name
documents, the insurance certicate and the bond (if required).
2. Provide any other name under which the applicant does business.
3. Indicate the type of business this is by putting a check in the appropriate box.
4. Provide the street address and the telephone number for the primary location of the business. If the business has
more than one primary location, a separate application must be completed. A separate application must be lled
out for all health care companies related through joint ownership, boards of directors, ofcers or principals.
5. Provide the business’ mailing address.
6. Provide the name, business and residence address and telephone number of the business’ registered agent if
applicable. If the managing agent is a corporation, association or another company, provide its name, street address
and telephone number, and the name and residence address of each of its ofcers and directors.
7. Indicate the business’ net worth and attach to the application the required insurance certicate(s) and the original bond. If
required, provide a certied nancial report.
8. Provide the business’ Federal Employer Identication Number.
9.(a-d) Answer these questions ONLY if the business is a sole proprietorship.
10. Provide the name, business and residence address, and telephone number of every ofcer, director and principal
and anyone who holds an ownership interest of 10% or more of the health care services rm. If the owner is a
general partnership, every partner must provide the requested information. Every individual responding to this question
must indicate the percentage of ownership held.
11. Provide a signed and notarized afdavit from every ofcer, director, partner, principal and owner indicating whether
he/she has ever been convicted of a crime. (See page 6 of the application.)
12. Provide a copy of the New Jersey license of the Health Care Practitioner Supervisor, Registered Nurse or
Licensed Physician employed by the agency.
Payment of the Registration Fee: The fee to register as a health care services rm is $500 for each primary location.
Payment must be submitted with the application. The certied check or money order should be made payable to the New
Jersey Division of Consumer Affairs.
Important Note: Please be advised that any application that is missing required information will be rejected. The entire
application must be completed and notarized. All of the requested documentation must be submitted with the application.
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Ofce of Consumer Protection
Regulated Business Section
124 Halsey Street, 7th Floor, P.O. Box 46016, Newark, NJ 07101
(973) 504-6370
Information that you provide on this application may be subject to public disclosure as required by the Open
Public Records Act (OPRA).
Instructions: Please print clearly. Answer all of the questions. Your application will not be processed until all of the questions
have been answered and all of the required documents, and the registration fee, have been received by this Division. If a question
does not apply to your business, write “N/A.”
1. Business Name
The name must match the name listed on the corporate, alternate name and trade name documents, the insurance certicate
and the original bond.
2. List all other names under which the applicant does business. If you do not use any other name(s), write “None.” If the
answer to this question is left blank, it will automatically default to “None.”
HCSF Form1-Rev. 5/10/19
Contact your local county
clerk’s ofce to obtain a Trade
Name Certicate.
Contact the N.J. Department
of the Treasury, Division
of Revenue, at (609) 292-9292,
if the business is a corporation.
Refer to the samples.
- 1 -
3. Indicate the type of business you own.
Sole Proprietorship: Attach a copy of the business’ Trade Name Certicate. Refer to Sample #1 or #2.
Partnership: Attach a copy of the business’ Trade Name Certicate. Refer to Sample #1 or #2.
Corporation:
Attach a copy of the business’ Certicate of Incorporation. Refer to Sample #3, #4 or #5.
Limited Liability Co.:
Attach a copy of the business’ Certicate of Formation. Refer to Sample #5, #6 or #7.
Limited Liability Partnership:
Attach a copy of your Certicate of Formation. Refer to Sample #5, #6 or #7.
Additional Requirements
Out-of-State Corporation: Attach a copy of the business’ New Jersey Certicate of Authority and the
formation documents from your home state. Refer to Sample #9.
Alternate Name: Attach a copy of the business’ Registration of Alternate Name Form C-150G. Refer to Sample #8.
Application for Registration as a Health Care Services Firm
4. Business Address (Must be a street address.) E-mail Address
City State ZIP Code
Telephone No. Fax No.
(include area code) (include area code)
5. Mailing Address If the address is the same as in question #4, write “N/A.”
5a.
Please provide the name of a contact person such as the administrative manager/supervisor, with their direct telephone
number and extension should the need arise for the Division to contact your agency.
6. Agent –
If the business is a corporation or an out-of-state corporation L.L.C., L.L.P., etc., you must provide the name and address
of an agent in New Jersey who is authorized to accept documents on its
behalf for the service of process.
Registered Agent’s Name
Street Address
City State: New Jersey ZIP Code
Telephone No. Fax No.
(include area code) (include area code)
Lawfully admitted
for permanent
residence in U.S.
- 2 -
□ □ □ - □ □ - □ □ □ □
□ □ - □ □ □ □ □ □ □
However, N.J.A.C. 13:45B-14.3(h) requires that every health care services rm maintain, or ensure the existence of, a
general liability insurance policy in the amount of $1,000,000 that shall insure against any placed health care practitioner’s
negligence, malpractice or any other unlawful conduct occurring within the scope of the health care practitioner’s placement.
Please submit with this application proof of having obtained the general liability insurance policy in the amount of $1,000,000.
You must attach your insurance certicate(s) or your application will not be processed.
7.
Is the business’ net worth equal to or greater than $100,000?
Yes No
If “Yes,” you are not required to obtain a surety bond. However, you must submit a report
certied by a C.P.A., stating that the applicant has a net worth of at least $100,000.00.
If “No,” you must submit with this application, the original surety bond in the amount of $10,000.
8. Provide the business’ Federal Employer Identication Number
Federal Employer Identication Number (FEIN)
Complete questions 9(a), 9(b), 9(c) and 9(d) ONLY if the business is run by a sole proprietor.
9(a).
Is the sole proprietor in default of a New Jersey or federal direct or guaranteed educational loan?
Yes No
9(b).
Is the sole proprietor the subject of a child-support warrant or has he/she failed to pay
Yes No
a court-ordered child-support obligation in an amount equal to or more than the amount of
child support payable for six months, failed to pay any court-ordered health care coverage
for the past six months or failed to respond to a subpoena relating to a paternity or
child-support proceeding?
9(c).
Check the appropriate box that indicates the sole proprietor’s citizenship/immigration status
.
U.S. Alien Other
citizen
9(d). Social Security number
*Pursuant to N.J.S.A. 54:50-24 et seq. of the New Jersey taxation law, N.J.S.A. 2A:17-56.44e of the New Jersey Child Support
Enforcement Law, Section 1128E(b)(2)A of the Social Security Act and 45 C.F.R. 60.7, 60.8 and 60.9, the Ofce of Consumer
Protection is required to obtain your Social Security number. Pursuant to these authorities, the Ofce of Consumer Protection
is also obligated to provide your Social Security number to:
a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for the purpose of
reviewing compliance with State tax law and updating and correcting tax records;
b. the Probation Division or any other agency responsible for child-support enforcement, upon request; and
c. the National Practitioner Data Bank and the H.I.P. Data Bank, when reporting adverse actions relating to health care
professionals.
10. List the full name, home and business street address and business telephone number of each owner, ofcer, director,
principal and person with an ownership interest of 10 percent or more in the business and the percentage of ownership
held. If the applicant is a partnership, each member of the partnership must be listed. (Use additional sheets of paper
if necessary.)
Please print clearly.
______________________________________________________________________________
Name and title
_______________________________________________________________________________________________________
Business street address City State ZIP code
_______________________________________________________________________________________________________
Home street address City State ZIP code
_______________________________________________
Business telephone number (include area code)
______________________________________________________________________________
Name and title
_______________________________________________________________________________________________________
Business street address City State ZIP code
_______________________________________________________________________________________________________
Home street address City State ZIP code
_______________________________________________
Business telephone number (include area code)
______________________________________________________________________________
Name and title
_______________________________________________________________________________________________________
Business street address City State ZIP code
_______________________________________________________________________________________________________
Home street address City State ZIP code
_______________________________________________
Business telephone number (include area code)
(Note: You may photocopy this page and attach additional pages to this application if there are more than three (3) owners,
ofcers, directors, principals or persons holding 10% or more interest in the health care services rm.)
- 3 -
You must indicate
Percentage of Ownership
____%
➦
You must indicate
Percentage of Ownership
____%
➦
You must indicate
Percentage of Ownership
____%
➦
11.
Pursuant to N.J.S.A. 34:8-44, if the agency is not a sole proprietorship, has every ofcer,
Yes No
director, partner, principal and owner holding 10% or more interest in the agency provided a
notarized
afdavit certifying whether or not he/she has ever been convicted of a crime?
(Have each of the relevant individuals complete and sign a copy of page six of this application, have it notarized and attach the
afdavit(s) to this application.)
12. Provide the address and telephone number for every primary location (i.e., an address used by the agency for 90 calendar days
or more to interview applicants, accept applications, or to solicit job orders from client companies).
If there are additional primary locations, please attach to this application a list of those locations as well as the location of
any other health care services rm related to the above-named health care services rm by joint ownership, boards of
directors, ofcers or principals.
13.
Provide a list of any licenses held in another state by the health care services rm, or by any ofcer, director, principal, owner
of 10% or more of the health care services rm, to provide health care services in another state, and a list of any actions taken
by another state on those licenses including violations of health or labor laws, and a description of any violations of federal law
by the health care services rm or any prinicpal of the health care services rm.
14.
Provide a copy of the New Jersey license of the Health Care Practitioner Supervisor, Registered Nurse or Licensed Physician
employed by the agency.
Payment of the Registration Fee:
The nonrefundable fee to register as a health care services rm is $500 for each primary location. Payment must be submitted with
the application. The certied check or money order should be made payable to the New Jersey Division of Consumer Affairs.
NOTE: Please be advised that any application that is missing required information will be rejected. The entire application must be
completed and notarized. All of the requested documentation must be submitted with the application.
Street address City/Town State ZIP code
Telephone number
(include area code)
- 4 -
AffidAvit for HeAltH CAre ServiCeS firm
This afdavit is to be executed by the applicant before a notary public:
State of: _____________________________________________
County of:___________________________________________
I,
___________________________________________ , in making this application to the New Jersey Division of
Consumer Affairs, Ofce of Consumer Protection, Regulated Business Section, for registration under the provisions of
Title 34 of the General Statutes of New Jersey and the Rules of the New Jersey Division of Consumer Affairs, Ofce of
Consumer Protection, Regulated Business Section, swear (or afrm) that I am the applicant and that all information
provided in connection with this application is true to the best of my knowledge and belief. I understand that any
omissions, inaccuracies or failure to make full disclosures may be deemed sufcient to deny registration or to
withhold renewal of or suspend or revoke a registration issued by the Division.
I further swear (or afrm) that I have read N.J.S.A. 34:8-45.1 et seq., together with the Rules and Regulations of
the New Jersey Division of Consumer Affairs, Ofce of Consumer Protection, Regulated Business Section,
N.J.A.C. 13:45B-13.2et seq., and fully understand that in receiving registration from the Division, I agree to be
bound by them.
Furthermore, I voluntarily consent to a thorough investigation of my present and past employment and other
activities for the purpose of verifying my qualications for registration. I further authorize all institutions, employers,
agencies and all governmental agencies and instrumentalities (local, state, federal or foreign) to release any
information, les or records requested by the Division.
_____________________________________________
Applicant’s signature
Sworn and subscribed to before me this ___________
day of _________________________ , ____________
Month Year
_____________________________________________
Name of Notary Public (please print)
_____________________________________________
Signature of Notary Public
Afx Seal Here
} ss.
- 5 -
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- 6 -
AffidAvit for eACH PArtner, offiCer And direCtor
This afdavit is to be executed by the applicant before a notary public:
State of: _____________________________________________
County of:___________________________________________
_____________________________________________ being duly sworn on his/her oath deposes and says:
1. I am the __________________________________ of _____________________________________ and I am ling
Title Name of Business
this afdavit in accordance with the requirements of N.J.S.A. 34:8-44.
2. (Please check one.)
a. ( ) I have never been convicted of a crime.
b. ( ) I have been convicted of a crime. An explanation of the pertinent details of all convictions follows:
(Attach an additional sheet of paper if more space is needed.)
_____________________________________________
Name of Principal (please print)
_____________________________________________
Principal’s signature
Sworn and subscribed to before me this ___________
day of _________________________ , ____________
Month Year
_____________________________________________
Name of Notary Public (please print)
_____________________________________________
Signature of Notary Public
All persons holding a ten (10) percent or greater pecuniary interest in the rm must submit a notarized afdavit.
If the applicant is a partnership, every member of the partnership must sign a notarized afdavit. In addition, if
the applicant is a corporation, each ofcer and director must sign a notarized afdavit.
Afx Seal Here
} ss.
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- 7 -
N.J. TRADE NAME CERTIFICATE
CERTIFICATE OF INCORPORATION
Page 1 Page 2
OUT-OF-STATE TRADE NAME CERTIFICATE
Note: The appearance of
these documents may vary
depending on the state and
county of origin.
SAMPLE FORMS
Page 1 Page 2
Sample #1 Sample #2
Sample #3 Sample #3
For information on documentation issued by the State of New Jersey call 609-292-9292 or visit www.state.nj.us/njbgs .
For information on a Trade Name Certificate issued in New Jersey contact your local county clerk’s office.
For information on documentation issued by another state or jurisdiction, contact the issuing authority for a copy of the document(s).
- 8 -
CERTIFICATE OF INCORPORATION
SAMPLE FORMS
Page 1 Page 2
Sample #4 Sample #4
Sample #5
Note: Sole Proprietor and Partnership documents are
issued by your local county clerk’s oce.
Certicate of Formation and Certicate of Incorporation
documents are issued by the State of New Jersey.
For information on documentation issued by the State of New Jersey call 609-292-9292 or visit www.state.nj.us/njbgs .
For information on a Trade Name Certificate issued in New Jersey contact your local county clerk’s office.
For information on documentation issued by another state or jurisdiction, contact the issuing authority for a copy of the document(s).
- 9 -
CERTIFICATE OF FORMATION
SAMPLE FORMS
CERTIFICATE OF FORMATION
Page 1 Page 2
Page 1 Page 2
Sample #6 Sample #6
Sample #7 Sample #7
For information on documentation issued by the State of New Jersey call 609-292-9292 or visit www.state.nj.us/njbgs .
For information on a Trade Name Certificate issued in New Jersey contact your local county clerk’s office.
For information on documentation issued by another state or jurisdiction, contact the issuing authority for a copy of the document(s).
- 10 -
CERTIFICATE OF LIABILITY INSURANCE
REGISTRATION OF ALTERNATE NAME CERTIFICATE OF AUTHORITY
Sample #8 Sample #9
Sample #10
For information on documentation issued by the State of New Jersey call 609-292-9292 or visit www.state.nj.us/njbgs .
For information on a Trade Name Certificate issued in New Jersey contact your local county clerk’s office.
For information on documentation issued by another state or jurisdiction, contact the issuing authority for a copy of the document(s).
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INSPECTION INFORMATION FOR APPLICANTS SEEKING TO OBTAIN A (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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