Blank Wisconsin F 62019 Form

Wisconsin F 62019 - Usage Guidelines

Completing the Wisconsin F 62019 form is a crucial step for those seeking to obtain a license for a nursing home, facility for the developmentally disabled, or an institute for mental disease. This form gathers essential information about the facility and its administration. It is important to ensure all sections are filled out accurately to avoid delays in the licensing process.

1. Begin by filling out the General Information section. Include the facility's name, any previous names, physical address, mailing address, city, county, state, zip code, telephone number, fax number, and email address.
2. Indicate the Level of License by checking the appropriate box: Skilled Care Nursing Home, Intermediate Care Nursing Home, Skilled Care Institute for Mental Disease, Intermediate Care Institute for Mental Disease, or Facility for the Developmentally Disabled. Also, provide the licensed bed capacity and type of certification.
3. Complete the Administration section. Provide the name and license number of the administrator, along with their status (permanent, acting, or interim). Indicate if the administrator is also the designee.
4. List the names of the Designee, Director of Nursing, and Medical Director, along with their respective statuses and start dates.
5. In the Ownership Information section, fill in the name and address of the applicant or licensee, including the type of organization (governmental, proprietary, voluntary non-profit, etc.).
6. List all Interested Parties with their names, principal business addresses, and ownership interest percentages. Attach additional pages if necessary.
7. Indicate whether the licensee owns the operation, building, or land by checking 'Yes' or 'No' for each category. If the licensee does not own them, provide the owner's information in the subsequent sections.
8. If applicable, fill out the Owner of the Operation section with the owner's name, address, and type of organization. Include interested parties as previously described.
9. Complete the Owner of the Building and/or Land sections if different from the operation. Provide the necessary details as outlined.

After completing the form, review all entries for accuracy. Ensure that all required information is provided, as the department will not issue a license without complete details. Once verified, submit the application to the designated address for processing.

When filling out the Wisconsin F-62019 form, there are several important do's and don'ts to keep in mind. Following these guidelines can help ensure that your application is processed smoothly.

• Do read the entire form carefully before starting. Understanding all sections will help you provide accurate information.
• Do provide complete and accurate information. Missing details can delay your application.
• Do include all required signatures. An unsigned application may be rejected.
• Do double-check your contact information. Ensure that your phone number and email address are correct for any follow-up communication.
• Do submit the form to the correct address. Make sure you send it to the Division of Quality Assurance in Madison.

• Don't rush through the form. Take your time to avoid errors that could lead to complications.
• Don't leave any sections blank unless instructed. If a question does not apply, write "N/A" instead.
• Don't forget to attach any necessary additional pages. If you need more space for ownership information, include it.
• Don't ignore the instructions regarding the type of organization. Selecting the wrong type can affect your application.
• Don't submit the form without a copy for your records. Keeping a copy can help in case of any issues later on.

Filling out the Wisconsin F 62019 form can be a daunting task, and many applicants make common mistakes that can delay the licensing process. One frequent error is failing to provide complete and accurate contact information. It's essential to ensure that all fields for names, addresses, and phone numbers are filled out correctly. Missing or incorrect details can lead to confusion and may result in the application being returned for corrections.

Another mistake is neglecting to specify the type of facility and license type. The form offers several options, including Nursing Home and Facility for the Developmentally Disabled. Applicants sometimes forget to check the appropriate box, which can lead to delays as the licensing department may need to clarify the intended facility type.

Inaccurate information about ownership is also a common pitfall. Applicants must list all interested parties and their ownership percentages. Omitting names or failing to provide correct ownership stakes can raise red flags during the review process. Ensure that all relevant individuals are included, and double-check the percentages to avoid discrepancies.

Many people overlook the section regarding the administrator's status. It's crucial to indicate whether the administrator is permanent, acting, or interim. This detail is vital for the department to assess the facility's management structure. Missing this information can lead to questions about the facility's operational stability.

Another frequent issue arises with the fiscal year end date. Applicants sometimes forget to include this critical piece of information. This date helps determine the facility's financial reporting and compliance, so it should be accurately provided.

Additionally, some applicants fail to include all necessary attachments. If there are additional pages required for listing interested parties or other relevant information, ensure they are included with the application. Incomplete submissions can result in processing delays.

It's also important to pay attention to the signature section. Some applicants forget to sign the form or have the wrong person sign it. The signature must be from the authorized individual who can legally bind the organization. A missing signature can halt the application process.

Lastly, applicants should be mindful of deadlines. Submitting the form late can affect the licensing timeline significantly. Ensure that the application is mailed to the correct address and sent well before any deadlines to avoid complications.

The Wisconsin F-62019 form is essential for applying for a license to operate a nursing home, facility for the developmentally disabled, or an institute for mental disease. Along with this form, several other documents are commonly required to ensure compliance with state regulations. Below is a list of related forms and documents that may be necessary during the licensing process.

• Caregiver Background Check Form: This document is used to conduct background checks on potential caregivers and staff members. It ensures that individuals working in the facility do not have a history that would disqualify them from providing care.
• Facility Policies and Procedures Manual: A comprehensive manual outlining the operational policies and procedures of the facility. This document is crucial for demonstrating compliance with health and safety regulations.
• General Power of Attorney Form: To manage financial affairs effectively, utilize the comprehensive General Power of Attorney document guidelines for proper documentation.
• Staffing Plan: This plan details the staffing structure of the facility, including the number of employees, their qualifications, and roles. It helps to ensure that the facility is adequately staffed to meet the needs of its residents.
• Financial Statements: Recent financial statements are often required to assess the financial viability of the facility. These documents provide insight into the facility's fiscal health and ability to operate sustainably.
• Emergency Preparedness Plan: This plan outlines the procedures the facility will follow in case of an emergency, such as a natural disaster or health crisis. It is vital for ensuring the safety of residents and staff.
• Inspection Reports: Previous inspection reports from health authorities may be required to show compliance with state regulations. These reports provide a history of the facility's adherence to health and safety standards.

These documents collectively support the application process for the Wisconsin F-62019 form. They help demonstrate the facility's commitment to quality care and compliance with state regulations. Submitting a complete application with all required documentation is crucial for obtaining a license.