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Fill Out Your Wisconsin F 62019 Template

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Outline

The Wisconsin F-62019 form serves as a crucial document for individuals and organizations seeking to obtain a license for operating a nursing home, a facility for the developmentally disabled, or an institute for mental disease in the state of Wisconsin. This form is required by specific state statutes and administrative codes, ensuring that all necessary information is collected to evaluate the eligibility for licensure. The application requests detailed information about the facility, including its name, address, and type of care provided, such as skilled or intermediate nursing care. Additionally, applicants must provide information about the administration of the facility, including the administrator's status and relevant qualifications. Ownership details are also essential; applicants must disclose the type of organization, ownership percentages, and the identities of individuals with significant authority over the facility. The completed form must be submitted to the Division of Quality Assurance, where it will be reviewed to determine compliance with state regulations. The personal information collected will be used solely for licensing purposes and statistical analysis, emphasizing the importance of accuracy and completeness in the application process.

Steps to Filling Out Wisconsin F 62019

Completing the Wisconsin F 62019 form is an essential step in the licensing process for nursing homes, facilities for the developmentally disabled, or institutes for mental disease. After filling out this form, you will need to submit it to the Division of Quality Assurance for review. Ensure that all sections are completed accurately to avoid any delays in processing your application.

  1. Begin with the General Information section. Fill in the facility's name and any previous name if applicable. Provide the physical address, mailing address (if different), city, county, state, and zip code. Include the telephone number, fax number, and email address.
  2. Indicate the Level of License you are applying for by checking the appropriate box: Skilled Care Nursing Home, Intermediate Care Nursing Home, Skilled Care Institute for Mental Disease, or Intermediate Care Institute for Mental Disease. Also, specify the licensed bed capacity and type of certification.
  3. In the Administration section, provide the name and license number of the administrator, along with the status (Permanent, Acting, or Interim). Include the begin date and indicate if the administrator is also the designee. If not, fill in the designee's name.
  4. Next, fill in the Director of Nursing and Medical Director sections with the respective names and begin dates.
  5. Move on to the Ownership Information section. List the applicant or licensee's name, physical address, mailing address, city, county, state, zip code, telephone number, contact person, and email address.
  6. Check the type of organization that applies to your facility, such as Governmental, Proprietary, or Non-Profit.
  7. In the Interested Parties section, list all names, principal business addresses, and percentage of ownership interest for all relevant parties. Attach additional pages if necessary.
  8. Complete the Ownership section, indicating if the licensee owns the operation, building, or land. Provide the names and addresses of the owners if the licensee is not the owner of these entities.
  9. If applicable, fill out the sections for the Owner of the Operation, Owner of the Building, and Owner of the Land with the required information, including names, addresses, and ownership percentages.
  10. Finally, review the entire form for accuracy and completeness before submission. Ensure all required signatures are included.

Once the form is completed, send it to the Division of Quality Assurance at the provided address. Keep a copy for your records, as you may need it for future reference or follow-up.

Key takeaways

When filling out the Wisconsin F 62019 form, there are several important points to keep in mind. Here are key takeaways to ensure a smooth application process:

  • Complete All Sections: Ensure that every section of the form is filled out completely. Missing information can delay the processing of your application.
  • Accurate Contact Information: Provide accurate contact details, including telephone numbers and email addresses. This allows the licensing department to reach you if they have questions.
  • Ownership Details: Clearly state the ownership structure of the facility. Include names and addresses of all individuals with a significant ownership interest.
  • Administrator Information: Include the name and license number of the administrator. If the administrator is acting in a temporary capacity, this should be noted as well.
  • Designee Section: If applicable, fill out the designee section for someone authorized to accept legal documents on behalf of the facility.
  • Submission Requirements: Submit the completed application to the Division of Quality Assurance at the provided address. Double-check that it is sent to the correct location.
  • Understand Licensing Types: Familiarize yourself with the different types of licenses and certifications available. This will help you select the appropriate one for your facility.

By following these guidelines, you can navigate the application process with confidence and clarity. Taking the time to ensure accuracy and completeness will facilitate a smoother experience with the licensing department.

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Documents used along the form

The Wisconsin F-62019 form is an essential document for individuals or organizations seeking to obtain a license for a nursing home, facility for the developmentally disabled, or an institute for mental disease. In conjunction with this form, several other documents may be required or beneficial for the application process. Below is a list of commonly used forms and documents that accompany the Wisconsin F-62019 form.

  • Wisconsin F-62018: This form is used for the application of a license for a community-based residential facility (CBRF). It collects similar information about the facility's ownership and administration.
  • Wisconsin F-62020: This document is a renewal application for existing facilities. It ensures that current facilities maintain compliance with state regulations and standards.
  • Wisconsin F-62021: This form is specifically for reporting changes in ownership or management of licensed facilities. It is crucial for maintaining updated records with the state.
  • Caregiver Background Check Form: This form is necessary for conducting background checks on individuals working in the facility. It helps ensure the safety and well-being of residents.
  • Facility Policies and Procedures Manual: A comprehensive document outlining the operational policies and procedures of the facility. This manual is often required for licensing and inspections.
  • Financial Statements: Recent financial documents may be needed to demonstrate the facility's financial stability and ability to provide care services.
  • Affidavit of Residency: To confirm your residence during various applications, refer to the essential Affidavit of Residency documentation for detailed guidance on proper completion.
  • Staffing Plan: This document outlines the staffing structure, including qualifications and roles of personnel, ensuring that the facility meets regulatory staffing requirements.
  • Emergency Preparedness Plan: A plan detailing how the facility will respond to emergencies, such as natural disasters or health crises. This is important for safeguarding residents and staff.
  • Inspection Reports: Previous inspection reports from state health departments may be requested to assess compliance with health and safety standards.

Each of these documents plays a vital role in the licensing process and helps ensure that facilities provide safe and effective care. It is important for applicants to gather and submit all required forms to facilitate a smooth licensing experience.