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Date: November 21, 2006
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State: Wisconsin
Category: Health Care
Author: SlateRA
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http://dhs.wisconsin.gov/forms1/F6/F62504.pdf

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DEPARTMENT OF HEALTH AND FAMILY SERVICES Office of Quality Assurance OQA-2504 (Rev. 10-06)

STATE OF WISCONSIN

For Office Use Only No. of Certified Programs or Programs Requesting Certification Amount Enclosed Date Report Received

$

AODA or MENTAL HEALTH CLINIC CERTIFICATION APPLICATION
Submission of this information is required by s. 50.065 and 51.45, Wis. Stats., and Chapters HFS 12, HFS 34 - 36, HFS 40, HFS 61 - 63 or HFS 75, Wisconsin Administrative Code. Failure to provide complete and accurate information may result in denial or revocation of certification. Questions about completion of this form may be directed to 608-243-2025 or [email protected]. Collection of the applicant's social security number or federal employer identification number is required per s. 73.0301, Wis. Stats. Failure to supply the number may result in denial of the application. This number will be disclosed only to the Department of Revenue for use in collection of tax delinquencies.

I. GENERAL INFORMATION ­ ENTITY REQUESTING CERTIFICATION Initial Certification
Name ­ Entity or Program

Change Of Ownership
Telephone Number

Entity Mailing Address (Street or PO Box, City, Zip Code)

Medicaid Certified Yes Fax Number

No

Entity Physical Address (if different from mailing address)

City

State

Zip

County

Web Address

Federal Employer Identification Number or Social Security Number Publish E-mail Address In Provider Directory Yes No

E-mail address (if any)

Name ­ Owner (see Part IV. Disclosure of Ownership)

Mailing Address ­ Owner (Street or PO Box, City, State, Zip Code)

Telephone Number

A. Has the applicant ever been convicted of a crime involving neglect or abuse of patients, or involved in assaultive behavior, wanton disregard for health and safety of others, or any act of elder abuse under s. 46.90, Wis. Stats.? Yes ­ Provide an explanation on an attached sheet. No B. Has the applicant ever had a denial, suspension, enjoining or revocation of a health care provider license, certification or approval as defined in s. 146.81, Wis Stats., or any conviction for providing health care without a license? Yes ­ Provide an explanation on an attached sheet. No

II. CAREGIVER BACKGROUND CHECKS
Entity Caregiver Background Checks must be completed for Entity Owners, whether or not the owner has direct client contact. They must also be completed for any board member who has direct client contact, and for non-client program residents. The on-site survey necessary for certification cannot be scheduled until the required ECBC forms are submitted to the Office of Caregiver Quality (OCQ) and certificates cannot be issued until the results are approved. If you have questions about this process, please call (608) 243-2036. · Complete a Background Information Disclosure (BID), form HFS-64; · Complete a Background Information Disclosure Appendix, form HFS-69; and · Include a $7.50 processing fee for each person, payable to "Office of Quality Assurance (OQA)". · Submit all forms with appropriate fees to:

Entity Background Checks Office of Quality Assurance / OQA 2917 International Lane, Suite 300 Madison, WI 53704

OQA ­ 2504(Rev. 10-06) Page 2

III. SERVICES PROVIDED AND FEE SCHEDULE A. CHECK BOX IN FRONT OF PROGRAMS REQUESTING CERTIFICATION:
HFS 75.04 HFS 75.05 HFS 75.06 HFS 75.07 HFS 75.08 HFS 75.09 HFS 75.10 HFS 75.11 HFS 75.12 HFS 75.13 HFS 75.14 HFS 75.15 HFS 75.16 HFS 62 CSAS / AODA Prevention Services Emergency Outpatient Medically Managed Inpatient Detox Med. Monitored Residential Detox Ambulatory Detoxification Residential Intoxication Monitoring Medically Managed Inpatient Medically Monitored Treatment Day Treatment Outpatient Treatment Transitional Residential Treatment Narcotic Treatment Intervention Services (proposed) Intox. Driver Assessments (proposed) HFS 61.71 HFS 61.75 HFS 61.79 HFS 61.91 HFS 34 Subchapter II HFS 34 Subchapter III HFS 40 Level 1 HFS 40 Level 2 HFS 40 Level 3 HFS 35 Mental Health Inpatient Treatment Day Treatment Adolescent Inpatient Outpatient Treatment Emergency Service 2 Emergency Service 3 Day Treatment Children 1 Day Treatment Children 2 Day Treatment Children 3 Outpatient Clinic Services (proposed)

PROGRAMS WITH SEPARATE FEE ASSESSMENTS* HFS 63 Community Support Program HFS 36 Comprehensive Community Services

B. FEE ASSESSMENT ­ THE FOLLOWING ARE THE INITIAL AND RECERTIFICATION FEES: No. of Programs 1 2 3 4 5+ Fee Due w/ Application $ 350.00 $ 500.00 $ 600.00 $ 675.00 $ 750.00

There are additional Branch Office and Telehealth fee assessments. Remit $200 per requested Branch Office (available to outpatient clinics only) and $200 for an entity's mental health and/or substance abuse treatment Telehealth Certification.

*Community Support Programs and Comprehensive Community Services are separate and distinct program types. Each requires a separate application and fee of $350, and each of which shall receive a separate certificate.
MAKE THE CHECK PAYABLE TO OFFICE OF QUALITY ASSURANCE IV. DISCLOSURE OF OWNERSHIP On attached sheets, list all names, principal business addresses and percentage of ownership interest of all officers, directors, stockholders owning 5% or more of stock, members, partners, or others having authority or responsibility for the operation of the organization. For non-profit organizations or governmental organizations, list the names and principal business addresses of all officers and board members. If there are no additional owners, see Part I, check here . V. AFFIRMATION I understand, under penalty of law, that the information provided above, and in attached application materials, is truthful and accurate to the best of my knowledge and that knowingly providing false information or omitting information may result in a fine of up to $10,000 or imprisonment not to exceed 6 years, or both (946.32 Wis. Stats.) I swear or affirm that I will comply with all laws, rules and regulations governing program certification in Wisconsin.

________________________________
Print or Type Name

__________________________________________________
SIGNATURE (In Full) - Designee

______________________________
Date Signed

__________________________________________________
TITLE (Must be Owner or Board Member)