(b) The application:

(1) Shall be on the form that the Secretary requires;

(2) Shall be signed and verified by the individual; and

(3) Shall include:

(i) The name of the applicant;

(ii) A statement that the applicant meets the requirements of this subtitle;

(iii) The location of the proposed hospice;

(iv) The name of the individual who is to be the medical director of the hospice care program; and

(v) Any other information that the Secretary requires.