Free Assisted Living Facility Request for Waiver, Approval, Variance or Exception-F-62548 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62548 (Rev. 04/09)

STATE OF WISCONSIN

ASSISTED LIVING FACILITY REQUEST FOR WAIVER, APPROVAL, VARIANCE OR EXCEPTION
Completion of this form is voluntary. Personal information collected on this form will be used during the review process and for no other purpose. Questions about completion of this form can be directed to the Division of Quality Assurance (DQA) Regional Office that served the facility. DQA Regional Offices are listed at: http://dhs.wisconsin.gov/rl_DSL/Contacts/alsreglmap.htm Return the completed and signed form to the appropriate DQA Regional Office address.
Check type of facility. CBRF Address (Street, City, State, Zip Code) Name ­ Resident Describe existing condition. City Applicable Codes State AFH County Zip Code License Number

Name ­ Facility

Alternate Proposal for Variance (Attach additional pages as necessary.)

Name - Person Completing This Form (Print or type.)

Title

Time Period This Request Covers From To Date Signed

SIGNATURE ­ Person Completing This Form

LICENSING SPECIALIST ACTION
Check one.

Approve Request; Expiration Date Deny Request
Justification

Waiver

Approval

Variance

Exception

Conditions

Name - Licensing and Certification Specialist

RFOD or RFOS Review Requested

Yes
RFOD or RFOS Comments

No

SIGNATURE - RFOD or RFOS

Date Signed