Form F-02564 "Mental Health or Substance Use Treatment Provider Initial Certification Application - DHS 40 and DHS 50" - Wisconsin

What Is Form F-02564?

This is a legal form that was released by the Wisconsin Department of Health Services - a government authority operating within Wisconsin. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2020;
  • The latest edition provided by the Wisconsin Department of Health Services;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form F-02564 by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

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Download Form F-02564 "Mental Health or Substance Use Treatment Provider Initial Certification Application - DHS 40 and DHS 50" - Wisconsin

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Quality Assurance
1 of 9
F-02564 (09/2020)
MENTAL HEALTH OR SUBSTANCE USE TREATMENT PROVIDER
INITIAL CERTIFICATION APPLICATION – DHS 40 and DHS 50
Questions regarding this form may be directed to the Division of Quality Assurance (DQA), Behavioral Health Certification Section
(BHCS) at 608-261-0656.
Submission of this information is required by Wis. Stat. §§ 50.065 and 51.45 and Wis. Admin. Code chs. DHS 40 and 50. Failure to
provide complete and accurate information may result in denial of the application and /or delay in the process . An application is
considered complete w hen all applications are received w ith accurate information, signatures, and supporting documentation, and w hen
the background check report resulting from Step 1 is available for review by the Behavioral Health Certification Section.
STEP 1 – ENTITY CAREGIVER BACKGROUND CHECKS (ECBC)
The applicant submits background information documents and fee directly to the Office of Caregiver Quality (OCQ). See below .
NOTE: Background m aterials should not be subm itted w ith the certification application.
ECBCs must be completed for entity ow ners, w hether or not the ow ner has direct client contact. Certification w ill not be issu ed until
the ECBC has cleared and results are approved.
For information on how to complete the ECBC, visit
http://dhs.w
isconsin.gov/caregiver/entity.htm.
For assistance completing this form, call OCQ at 608-261-8319.
STEP 2 – COMPLETED APPLICATION
The applicant submits all applicable documents listed in this section and the BHCS staff w ill review to ensure compliance w ith
applicable regulations.
A completed application includes each of the follow ing
1.
This application form, fully completed and signed by the entity ow ner or board member
2.
All supporting documentation as specified in the application
3.
Fees as specified in the application
Mail the completed application to: DHS / DQA / Behavioral Health Certification Section
PO Box 2969
Madison, WI 53701-2969
STEP 3 – ONSITE SURVEY
A BHCS surveyor w ill contact you to arrange a date and time for an onsite survey.
Refer to DQA publication
P-63174, Survey Guide: Behavioral Health Certification for Mental Health and Substance Abuse
Services.
Review applicable checklists for each administrative rule at the DQA w ebpage,
Mental Health Treatment Programs: Certification
Information.
If the surveyor identifies significant changes that w ould result in a denial decision, the applicant w ill be afforded an opportunity to
make necessary changes and submit those changes for review .
STEP 4 – APPROVAL OR DENIAL DECISION
The surveyor w ill make the certification decision and send the survey results to notify the provider of the decision.
If approved, BHCS staff w ill mail a formal certificate to the provider for posting at the primary clinic location.
GENERAL INFORMATION – ENTITY / ENTITY OWNER REQUESTING CERTIFICATION
I.
Change of Ow nership – Provide current certification number.:
Initial Certification
A. Entity Contact Information
Name – Program
Will program obtain Medicaid certification?
Yes
No
Telephone No.
Fax No.
Web Address (if any)
Physical Address – Street
City
County
State
Zip Code
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Quality Assurance
1 of 9
F-02564 (09/2020)
MENTAL HEALTH OR SUBSTANCE USE TREATMENT PROVIDER
INITIAL CERTIFICATION APPLICATION – DHS 40 and DHS 50
Questions regarding this form may be directed to the Division of Quality Assurance (DQA), Behavioral Health Certification Section
(BHCS) at 608-261-0656.
Submission of this information is required by Wis. Stat. §§ 50.065 and 51.45 and Wis. Admin. Code chs. DHS 40 and 50. Failure to
provide complete and accurate information may result in denial of the application and /or delay in the process . An application is
considered complete w hen all applications are received w ith accurate information, signatures, and supporting documentation, and w hen
the background check report resulting from Step 1 is available for review by the Behavioral Health Certification Section.
STEP 1 – ENTITY CAREGIVER BACKGROUND CHECKS (ECBC)
The applicant submits background information documents and fee directly to the Office of Caregiver Quality (OCQ). See below .
NOTE: Background m aterials should not be subm itted w ith the certification application.
ECBCs must be completed for entity ow ners, w hether or not the ow ner has direct client contact. Certification w ill not be issu ed until
the ECBC has cleared and results are approved.
For information on how to complete the ECBC, visit
http://dhs.w
isconsin.gov/caregiver/entity.htm.
For assistance completing this form, call OCQ at 608-261-8319.
STEP 2 – COMPLETED APPLICATION
The applicant submits all applicable documents listed in this section and the BHCS staff w ill review to ensure compliance w ith
applicable regulations.
A completed application includes each of the follow ing
1.
This application form, fully completed and signed by the entity ow ner or board member
2.
All supporting documentation as specified in the application
3.
Fees as specified in the application
Mail the completed application to: DHS / DQA / Behavioral Health Certification Section
PO Box 2969
Madison, WI 53701-2969
STEP 3 – ONSITE SURVEY
A BHCS surveyor w ill contact you to arrange a date and time for an onsite survey.
Refer to DQA publication
P-63174, Survey Guide: Behavioral Health Certification for Mental Health and Substance Abuse
Services.
Review applicable checklists for each administrative rule at the DQA w ebpage,
Mental Health Treatment Programs: Certification
Information.
If the surveyor identifies significant changes that w ould result in a denial decision, the applicant w ill be afforded an opportunity to
make necessary changes and submit those changes for review .
STEP 4 – APPROVAL OR DENIAL DECISION
The surveyor w ill make the certification decision and send the survey results to notify the provider of the decision.
If approved, BHCS staff w ill mail a formal certificate to the provider for posting at the primary clinic location.
GENERAL INFORMATION – ENTITY / ENTITY OWNER REQUESTING CERTIFICATION
I.
Change of Ow nership – Provide current certification number.:
Initial Certification
A. Entity Contact Information
Name – Program
Will program obtain Medicaid certification?
Yes
No
Telephone No.
Fax No.
Web Address (if any)
Physical Address – Street
City
County
State
Zip Code
F-02564 (09/2020)
2 of 9
DESIGNAT ED MAIL RECIPIENT
Provide name and contact information of person to whom ALL mail from DHS / DQA is to be addressed.
Name – Designated Mail Recipient
Title
Email Address
Mailing Address – Street or PO Box (if different from above)
City
State
Zip Code
B. Entity Owner Information
Type of Entity (Check only one.)
Government – County
Church
Tribal
Partnership
Corporation – Business
Government – State
Other – Specify below:
Limited Liability Corp (LLC)
Corporation – Non Profit
Government – Other
Proprietorship (Individual)
Name – Ow ner (Individual / Partnership Names) or Corporation (Legal Entity)
FEIN* – Legal Entity
Name – Ow ner / Board Member
SSN* – Ow ner or Board Member
Address – Street
City
State
Zip Code
Telephone – Ow ner / Board Member
Fax – Ow ner / Board Member
Email Address – Ow ner / Board Member
* Collection of the applicant’s Social Security number (SSN) and Federal Employer Identification number (FEIN), if applicable , is
required per Wis. Stat. § 73.0301 to verify compliance with Wis. Stat. § 51.032. Failure to supply the number may result in denial of the
application. This number will only be disclosed to the Department of Revenue for use in collection of tax delinquencies.
C. Program Information
Nam e
Telephone No.
Fax No.
Em ail Address
Program Contact
Client Rights Specialist
Program Director / Administrator
Clinical Coordinator
Record Custodian
Yes
No
Have you informed your clients (both former and present) that they may be contacted by the DQA surveyor?
Are you accredited by any organizations, other than DQA? If “yes,” identify accreditation organization and provide
Yes
No
accreditation identification.
Does your agency have a contract w ith the 51.42 Board? If “yes,” identify county / counties.
Yes
No
F-02564 (09/2020)
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Yes
No
Have you every operated a residential facility, health care facility, or day care program for adults or children in
Wisconsin or in any other state? If “yes,” explain and provide relevant information.
D. Disclosure of Ownership
Required Supporting Docum entation – Submit these required documents, when applicable:
1.
List of names, principal business address, and percentage of ow nership interest of all officers, directors, stockholders
ow ning 5% or more of stock, members, partners, or others having authority or responsibility for the operation of the
organization. For non-profit or governmental organizations, list the names and principal business addresses of all officers
and board members.
2.
A diagram reflecting the ow nership structure and names of any affiliate organization associated w ith the entity ow ner
(parent corporations, other LLC, partnership, etc.)
If there are no additional ow ners, check here.
E. Entity Owner Attestation
I hereby attest that all staff know and understand the rights of the clients that they serve and the procedures of informal and formal
resolution and have read Wis. Admin. Code chs. DHS 92 and 94. The above-named program has appropriate policies to meet Wis.
Admin Code chs. DHS 92 and 94 to ensure patient rights, patient records, confidentiality, and informed consent. The program has a
designated client rights specialist w ho is trained in compliance w ith the requirements of Wis. Admin. Code chs. DHS 92 and 94, Wis.
Stat. ch. 51, and federal HIPAA requirements in 45 CFR 164 Part E and 42 CFR Part 2, as applicable.
I attest, under penalty of law , that the information provided in this application and in attached application materials is tr uthful and
accurate to the best of my know ledge and that know ingly providing false information or omitting information may result in a fine of up to
$10,000 or imprisonment not to exceed six years, or both (Wis. Stat. § 946.32).
I attest that I w ill comply w ith all law s, rules, and regulations governing program certification in Wisconsin.
SIGNATURE – Ow ner or Board Member (Full signature is required.)
Date Signed
Name – Ow ner or Board Member (Print or type.)
Title – Ow ner or Board Member
F. Entity Owner Transfer of Responsibility to Request Future Changes and Clinical Operations
The individual in the role specified below is given full authority to request initial services and branches, service additions and deletions,
staff changes, branch location additions and deletion, and all operational changes submitted to the department.
Check applicable role:
Program Contact
Program Director / Administrator
Clinical Coordinator
SIGNATURE – Ow ner or Board Member (Full signature is required.)
Date Signed
Name – Ow ner or Board Member (Print or type.)
Title – Ow ner or Board Member
F-02564 (09/2020)
4 of 9
II. INITIAL SERVICES CERTIFICATION
Indicate which services will be offered; review and complete the section fully; and, submit the specified additional documentation.
DHS 40 – Mental Health Day Treatment Services for Children
Type of Organization
A.
(See Wis. Admin. Code §§ DHS 40.03(10) and (20) for definitions.)
Community-based program
Intensive hospital-based program
Required Supporting Documentation
B.
(Submit these required documents specific to Wis. Admin. Code ch. DHS 40.)
Program description outlining each item listed in Wis. Admin. Code § DHS 40.04(1)(b)2.c
Policies and procedures that meet the requirements of Wis. Admin. Code § DHS 40.07(1)
The follow ing documents show ing compliance w ith Wis. Admin Code chs. SPS 361-366 per Wis. Admin. Code § DHS
40.04(1)(b)2.c.6:
If existing building:
Municipal zoning approval documentation or occupancy permit
If new building construction or newly remodeled building:
1.
State agency or municipal agent plan review approval letter (written, signed) that specifically identifies compliance w ith
the Wisconsin Commercial Building Code (Wis. Admin. Code chs. SPS 361-366) and accessibility requirements (ADA).
Link to Wisconsin Municipalities w ith Commercial Buildings Delegated Authority
2.
State agency or municipal agent inspection report (written, signed) that specifically identifies compliance w ith the
Wisconsin Commercial Building Code (Wis. Admin. Code chs. SPS 361-366) and accessibility requirements (ADA).
3.
DQA form
F-62495, Compliance
Statement, completed by the ow ner and representative design professional that
specifically identifies compliance w ith the Wisconsin Commercial Building Code (Wis. Admin. Code chs. SPS 361 -366)
and accessibility requirements (ADA).
C. Attestation
I hereby attest that all statements made in this application and any attachments are correct to the best of my know ledge and that I w ill
comply w ith all law s, rules, and regulations governing DHS 40 services, including Wis. Admin. Code chs. DHS 92 and 94 and Wis . Stat.
ch. 51. The signatory of this document is duly authorized by the licensee / certificate holder to sign this agreement on its behalf. The
certificate holder hereby accepts responsibility for know ing and ensuring compliance w ith all licensing, operational, and req uirements
for this facility.
I attest under penalty of law that the information provided above is truthful and accurate to the best of my know ledge.
I understand that know ingly providing false information or omitting information may result in denial of licensure, a fine of up to $10,000
or imprisonment not to exceed six years, or both (Wis. Stat. § 946.32).
SIGNATURE – Entity Ow ner, Representative, or Authorized Representative Specified Above
Date Signed
Full Name (Print or type.)
Title
F-02564 (09/2020)
5 of 9
DHS 50 – Youth Crisis Stabilization Facility (YCSF)
Note: Per Wis. Stat. § 51.042(2)(a), the department may limit the number of certifications it grants to operate a YCSF.
Before applying for certification, perspective providers must receive approval from the Division of Care and Treatment
Services (DCTS).
Required Supporting Documentation
A.
(Submit these required documents specific to Wis. Admin. Code ch. DHS 50.)
DCTS approval letter
A program statement, as specified under Wis. Admin. Code § DHS 50.05
A copy of the YCSF’s policies and procedures, as specified under Wis. Admin. Code DHS 50.06
A floor plan of the YCSF specifying dimensions, exits, and planned room usage [See §§ DHS 50.15(2) and (6).]
All inspection reports completed during the last 12 months, as defined in Wis. Admin. Code §§ 50.15-50.18
1. If private w ater supply, annual w ell w ater test results [See Wis. Admin. Code § DHS 50.15(3)(a)2.]
2. If private sew er system, sew er test results indicating system is sized appropriately for intended use [See Wis. Admin.
Code § DHS 50.15(3)b.]
3. Annual inspection of smoke detection system [See Wis. Admin. Code § DHS 50.17(1).]
4. Annual fire inspection [See Wis. Admin. Code § DHS 50.17(4).]
Proof of building insurance [See Wis. Admin. Code § DHS 50.03(2)(h).]
Proof of risk and liability insurance [See Wis. Admin. Code § DHS 50.03(2)(h).]
Proof of vehicle insurance, if transporting youth [See Wis. Admin. Code § DHS 50.03(2)(h).]
Payment of any forfeitures, fees, assessments related to any licenses or certifications issued by the department to the
applicant, or a w ritten statement signed by an authorized representative stating that no fees, forfeitures, assessments are
ow ed
The follow ing documents show ing compliance w ith Wis. Admin. Code chs. SPS 361-366 per Wis. Admin. Code DHS 50.15(1):
If existing building:
Municipal zoning approval documentation or occupancy permit
If new building construction or newly remodeled building:
1.
State agency or municipal agent plan review approval letter (written, signed) that specifically identifies compliance w ith
the Wisconsin Commercial Building Code (Wis. Admin. Code chs. SPS 361-366) and accessibility requirements (ADA).
Link to Wisconsin Municipalities w ith Commercial Buildings Delegated Authority
2.
State agency or municipal agent inspection report (written, signed) that specifically identifies compliance w ith the
Wisconsin Commercial Building Code (Wis. Admin. Code chs. SPS 361-366) and accessibility requirements (ADA)
3.
DQA form
F-62495, Compliance Statement,
completed by the ow ner and representative design professional that
specifically identifies compliance w ith the Wisconsin Commercial Building Code (Wis. Admin. Code chs. SPS 361 -366)
and accessibility requirements (ADA)
B. Attestation
I hereby attest that all statements made in this application and any attachments are correct to the best of my know ledge and that I w ill
comply w ith all law s, rules, and regulations governing DHS 50 services, including Wis. Admin. Code chs. DHS 92 and 94 and Wis. Stat.
ch. 51. The signatory of this document is duly authorized by the licensee / certificate holder to sign this agreement on its behalf. The
certificate holder hereby accepts responsibility for know ing and ensuring compliance w ith all licensing, operational, and req uirements
for this facility.
I attest under penalty of law that the information provided above is truthful and accurate to the best of my know ledge.
I understand that know ingly providing false information or omitting information may result in denial of licensur e, a fine of up to $10,000
or imprisonment not to exceed six years, or both (Wis. Stat. § 946.32).
SIGNATURE – Entity Ow ner, Representative, or Authorized Representative Specified Above
Date Signed
Full Name (Print or type.)
Title
Page of 9