Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES
F-82069A (07/09)

STATE OF WISCONSIN

BACKGROUND INFORMATION DISCLOSURE (BID) APPENDIX INSTRUCTIONS
License Holders and Non Client Residents in Division of Quality Assurance Regulated Facilities
This Background Information Disclosure (BID) Appendix gathers information for Division of Quality Assurance (DQA) regulated facilities. Complete and return this BID Appendix with your F-82064 BID each time the forms are requested by DQA.

SECTION 1 ­ REQUIRED INDIVIDUALS
Check the most appropriate box in Section 1. For non-governmental entities: · The license holder/legal representative of the entity must submit a BID (F-82064) form and Appendix whether or not you have regular, direct contact with clients. NOTE: If the owner is a corporation or other type of business that does not have a single owner (e.g., domestic corporation, non stock corporation, partnership, limited liability company), then the organization must designate one person to legally represent the organization for the purposes of fulfilling the background check requirements. · Principal officers, corporation, or board members of the business organization if they have regular, direct contact with clients. · Non client residents (age 10 and older) of the entity if they have regular, direct contact with clients. For governmental and tribal entities: · An individual (e.g., the entity administrator designated by the government agency or tribe) who operates the entity must submit a BID form and Appendix whether or not the person has regular, direct contact with clients. · Non client residents (age 10 and older) of the entity if they have regular, direct contact with clients.

SECTION 2 ­ PERSONAL INFORMATION
Complete all requested information.

SECTION 3 ­ SPECIFIC FACILITY INFORMATION
Complete the information for the specific facility that you own or legally represent, including facility name, address, license/certification/registration number (if the number appears on the facility license/certificate) and entity type code. See below. Code 34 40 61 63 75 82 83 88 Entity Type Emergency Mental Health Service Programs Mental Health Day Treatment Services for Children Community Mental Health Developmental Disabilities Community Support Program AODA Certified Adult Family Homes Community Based Residential Facilities Licensed Adult Family Home Code 89 124 127 131 132 133 134 000 Entity Type Residential Care Apartment Complexes Hospitals Rural Medical Centers Hospices Nursing Homes Home Health Agencies Facilities for the Developmentally Disabled Other (Specify.)

4 Year Renewal Only: If you are the license holder/legal representative for multiple facilities, you may submit one BID and one BID Appendix if you check the box in Section 3 of the BID Appendix; and attach a list of all DQA regulated facilities, including the specific facility name, facility address (Street, City, State, Zip Code), facility license or certification number, if known, and facility type for each license, certification or registration.

SECTION 4 ­ BUSINESS INFORMATION
If the license holder is a corporation or other type of business that does not have a single owner (e.g. domestic corporation, non stock corporation, partnership, limited liability company) complete the business office information.

SECTION 5 ­ BACKGROUND CHECK FEE
Include a $10.00 processing fee for each person, payable to the "Division of Quality Assurance." The processing fee is required at the time of initial license application and 4 year renewal. If you are the license holder/legal representative of an existing facility and are completing an application for a new facility, you must complete the forms but may omit the fee. DQA will contact you if the fee is required.

F-82064 SECTION B ­ ADDITIONAL DOCUMENTATION
· · Military Service. If you were discharged from the US Armed Forces within the past 3 years, you must submit a copy of your military discharge papers (DD-214) with the BID and BID Appendix forms. Out-of-State Residency. If you resided outside of Wisconsin in the last 3 years, you must submit a copy of your criminal history from the other state(s) with the BID and BID Appendix forms. For more information refer to http://www.doj.state.wi.us/dles/cib/sclist.asp.

Submit the completed BID and BID Appendix and other documentation described above, if appropriate, with the fee to: Entity Background Checks Division of Quality Assurance P.O. Box 2969 Madison, WI 53701-2969 Please submit only the forms and fee for the license holder/legal representative, board members, and non client residents to DQA.

DEPARTMENT OF HEALTH SERVICES F-82069 (07/09)

STATE OF WISCONSIN Chapter 50.065, Wis. Stats.

BACKGROUND INFORMATION DISCLOSURE (BID) APPENDIX
License Holders and Non Client Residents in Division of Quality Assurance Regulated Facilities

DQA USE ONLY Initial Application 4 Year Renewal

Completion of this Appendix is required under the provisions of Chapter 50.065, Wis. Stats. Failure to comply may result in a denial or revocation of your license, certification, or registration. Refer to the attached Appendix instructions (F-82069A) for additional information. Providing your social security number is voluntary; however, your social security number is one of the unique identifiers used to prevent incorrect matches. Complete this BID Appendix and submit it with the completed Background Information Disclosure (F-82064) form to the address specified in the Appendix instructions. SECTION 1 ­ REQUIRED INDIVIDUALS Non-governmental Entities (Check the most appropriate box.) License holder/legal representative of an existing facility Applicant for a new facility license or certification or registration Governmental and Tribal Entities (Check the most appropriate box.) Entity Administrator/Operator Applicant for a new facility license or certification or registration SECTION 2 ­ PERSONAL INFORMATION
Social Security Number Name - First Name - Middle Initial Name - Last Birth Date Gender Male Race Female

Principal officer, corporation or board member Non client resident (age 10 and older) Non client resident (age 10 and older)

Other Names By Which You Have Been Known (Including Maiden Name)

Black (not of Hispanic origin) Asian or Pacific Islander
Home Address

American Indian or Alaskan Native Hispanic (Mexican, Puerto Rican, Cuban, or Spanish culture)
City

White (not of Hispanic Origin) Other
State Zip Code

SECTION 3 ­ SPECIFIC FACILITY INFORMATION Check here if a list of facilities is attached. (See instructions for more information.)
Job Title/Relationship to Facility Name ­ Facility Street Address ­ Facility Contact Person ­ Facility Work Telephone Number License/Certification/Registration Number City State Entity Type Code Zip Code

Contact Telephone Number

SECTION 4 ­ BUSINESS INFORMATION
Business Name ­ Corporation/Organization Street Address ­ Corporation/Organization Contact Person ­ Corporation/Organization City State Zip Code

Contact Telephone Number

SECTION 5 ­ BACKGROUND CHECK FEE Fee Included: Initial application for new facility 4 year renewal for existing facility Fee Not Included: Existing license holder/legal representative completing an application for a new facility

Please read and initial the following statements. _________ I have completed and reviewed the attached BID (F-82064) and affirm that the information is true and correct as of today's date. _________ I understand that I must report changes, pending charges, and/or convictions to the Department within one (1) business day. SIGNATURE ­ Required Individual Date Signed