Form F-00571 "Emergency Mental Health Service Recertification Application - DHS 34" - Wisconsin

What Is Form F-00571?

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 March 1, 2013;
  • The latest edition provided by the Wisconsin Department of Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form F-00571 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-00571 "Emergency Mental Health Service Recertification Application - DHS 34" - Wisconsin

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Quality Assurance
Chapter DHS 34, Wis. Admin. Code
F-00571 (03/2013)
EMERGENCY MENTAL HEALTH SERVICE
RECERTIFICATION APPLICATION
DHS 34
This application is to verify that the emergency mental health service complies with DHS 34, Wis. Admin. Code. By completing and
submitting this form, the clinic indicates that it is in compliance with the program standards as required by state statutes.
The checkboxes denote a required response, form, or attachment to the application
Each abstract should be limited to one page in length.
Label each application page with the identifying question number / letter.
Name - Facility
Certification Number
Address – Physical
City
State
Zip Code
County
Telephone Number
E-mail Address
May be published in Provider Directory.
(
)
Fax Number
Internet Address
May be published in Provider Directory.
(
)
Name - Contact Person
Telephone Number
E-mail Address
May be published in Provider Directory.
(
)
Name – Person Who Completed this Form
Telephone Number
E-mail Address
May be published in Provider Directory.
(
)
I hereby attest that all statements made in this application and any attachments are correct to the best of my knowledge
and that I will comply with all laws, rules, and regulations governing crisis services.
SIGNATURE – Director
Date Signed
Full Name – Director (Print or type.)
1.
DHS 34.11 (1) General
YES
NO
The emergency mental health service complies with the requirements for a basic emergency service as
described in DHS 34.11.
2.
DHS 34.11 (2) Personnel
This service complies with requirements in DHS 75.03 that apply to prevention services.
a.
Complete and attach a current “Treatment Staff” form to this application.
b.
If your agency is contracted with a 51.42 Board, provide a list of contracted counties.
c.
Provide an abstract of volunteer personnel orientation and training plans. Include the name of a regular
staff member that is available at all times to assist with the volunteers.
d.
Provide names of those available for medical consultations available to all staff members at all times.
e.
Provide names of those available for psychiatric consultation available to all staff members at all times.
f.
Please have available for review, copies of degrees, certificates, and/or licenses.
3.
DHS 34.11 (3) Program Operation and Content
YES
NO
a.
Emergency services are available 24 hours a day, seven days a week.
YES
NO
b.
A 24-hour a day crisis telephone services is available.
c.
Indicate who answers the emergency telephone.
Mental health professionals
Paraprofessionals
Trained mental health volunteers
d.
Provide an abstract of written guidelines for referrals and schedules of professional staff to serve as
back-up when paraprofessional/volunteers answer the phones.
e.
Provide an abstract of face-to-face contact for crisis intervention services that you provide.
Provide an abstract of client transfer policies, procedures, and names of facilities with which you
f.
share your emergency services.
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Quality Assurance
Chapter DHS 34, Wis. Admin. Code
F-00571 (03/2013)
EMERGENCY MENTAL HEALTH SERVICE
RECERTIFICATION APPLICATION
DHS 34
This application is to verify that the emergency mental health service complies with DHS 34, Wis. Admin. Code. By completing and
submitting this form, the clinic indicates that it is in compliance with the program standards as required by state statutes.
The checkboxes denote a required response, form, or attachment to the application
Each abstract should be limited to one page in length.
Label each application page with the identifying question number / letter.
Name - Facility
Certification Number
Address – Physical
City
State
Zip Code
County
Telephone Number
E-mail Address
May be published in Provider Directory.
(
)
Fax Number
Internet Address
May be published in Provider Directory.
(
)
Name - Contact Person
Telephone Number
E-mail Address
May be published in Provider Directory.
(
)
Name – Person Who Completed this Form
Telephone Number
E-mail Address
May be published in Provider Directory.
(
)
I hereby attest that all statements made in this application and any attachments are correct to the best of my knowledge
and that I will comply with all laws, rules, and regulations governing crisis services.
SIGNATURE – Director
Date Signed
Full Name – Director (Print or type.)
1.
DHS 34.11 (1) General
YES
NO
The emergency mental health service complies with the requirements for a basic emergency service as
described in DHS 34.11.
2.
DHS 34.11 (2) Personnel
This service complies with requirements in DHS 75.03 that apply to prevention services.
a.
Complete and attach a current “Treatment Staff” form to this application.
b.
If your agency is contracted with a 51.42 Board, provide a list of contracted counties.
c.
Provide an abstract of volunteer personnel orientation and training plans. Include the name of a regular
staff member that is available at all times to assist with the volunteers.
d.
Provide names of those available for medical consultations available to all staff members at all times.
e.
Provide names of those available for psychiatric consultation available to all staff members at all times.
f.
Please have available for review, copies of degrees, certificates, and/or licenses.
3.
DHS 34.11 (3) Program Operation and Content
YES
NO
a.
Emergency services are available 24 hours a day, seven days a week.
YES
NO
b.
A 24-hour a day crisis telephone services is available.
c.
Indicate who answers the emergency telephone.
Mental health professionals
Paraprofessionals
Trained mental health volunteers
d.
Provide an abstract of written guidelines for referrals and schedules of professional staff to serve as
back-up when paraprofessional/volunteers answer the phones.
e.
Provide an abstract of face-to-face contact for crisis intervention services that you provide.
Provide an abstract of client transfer policies, procedures, and names of facilities with which you
f.
share your emergency services.
F-00571 (03/2013)
Page 2 of 2
EMERGENCY MENTAL HEALTH TREATMENT STAFF LISTING
Name – Facility
Facility Address – Street Address
City
Zip Code
Knowledge of
Name
Position
Verification Signature *
Date
Degree
Applicable Parts of
Chapters 48, 51, 55
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
*
VERIFICATION SIGNATURE – Verifies that the above experience and knowledge factors are correct and that there is a criminal record check on file.
I affirm that the above statements are correct to the best of my knowledge.
SIGNATURE – Facility Director
Name – Facility Director (Print or type.)
Date Signed
Page of 2