Free Adult Family Home Renewal of Certification Grandfathering Request - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20439 (08/2008)

STATE OF WISCONSIN

ADULT FAMILY HOME (AFH) RENEWAL OF CERTIFICATION GRANDFATHERING REQUEST
Completion of this form is voluntary. Failure to complete this form may result in delayed processing of the request. Return completed forms to: Carrie Molke, LTC Residential Policy Specialist, Bureau of Long-Term Support via fax: 608-267-2913, e-mail: [email protected], or via mail: P. O. Box 7851, Madison 53707-7851. County Name of Person Completing Request Telephone Number Fax Number Date of Request Title E-Mail Address Date Certified as AFH

Name of Adult Family Home Address City Name of Participant Explain the situation and reason why grandfathering is necessary State

Zip Code Date Entered AFH

Explain the consequence if grandfathering is not granted

Explain how you have attempted to comply with the new standards

Explain how health and safety will be assured

Department Use Only Approved Denied--Reason: _______________________________________________________________ Date __________________________