Type of Licensee (Check only one. Do not facility will be owned and operated by a state agency.) check “Government – State” unless Church Government County Limited Liability Corporation (LLC) – Corporation For-Profit Government State Partnership – Corporation Non-Profit Government Other Proprietorship (individual) – Tribal Other Specify: – Licensee Information Name Corporation / Legal Entity (if applicable) FEIN (Federal Employer Identification No.) – Name Licensee or Corporate Representative Birthdate Licensee or Corporate Rep. – – Address Licensee / Corporate Representative City State Zip Code – Telephone No. Fax No. Email Address Provide the name(s) of any other facilities associated with this licensee or corporate entity. Attach an additional list if necessary. Resident Information Total Resident Capacity: Female Male Both Check only the box(es) indicating the primary client group(s) you will serve. Note: If more than one client group is selected, the statement must explain how compatibility is assured. [Wis. Admin. Code § DHS 83.06(1)(e)] facility’s program AA Advanced Age ALZ Irreversible Dementia / – – Alzheimer’s AODA Alcohol / Drug Dependent PD Physically Disabled – – CC Correctional Clients PWC Pregnant Women Who Need Counseling – – DD Developmentally Disabled (Intellectually Impaired) TI Terminally Ill – – MH Emotionally Disturbed / Mental Illness TBI Traumatic Brain Injury – – Will you accept public funding? Yes No To be eligible to receive public funding, facilities must demonstrate compliance with The Centers for Medicare & Medicaid Services (CMS) Home and Community-Based Services (HCBS) settings rule during the onsite survey. Review the additional requirements listed on page 5 of this application. List any days and hours when residents are not usually in the facility. Days Hours Indicate the minimum and maximum monthly fees charged for resident care. If you charge the same fee to all residents, indicate the amount as your maximum rate. Minimum Monthly Rate Per Individual Maximum Monthly Rate Per Individual
Type of Licensee (Check only one. Do not check “Government – State” unless facility will be owned and operated by a state agency.) Church Corporation For-Profit Corporation Non-Profit Government – County Government – State Government – Other Tribal Limited Liability Corporation (LLC) Partnership Proprietorship (individual) Other – Specify: Licensee Information Name – Corporation / Legal Entity (if applicable) FEIN (Federal Employer Identification No.) Name – Licensee or Corporate Representative Birthdate – Licensee or Corporate Rep. Address – Licensee / Corporate Representative City State Zip Code Telephone No. Fax No. Email Address Provide the name(s) of any other facilities associated with this licensee or corporate entity. Attach an additional list if necessary. Resident Information Total Resident Capacity: Female Male Both Check only the box(es) indicating the primary client group(s) you will serve. Note: If more than one client group is selected, the facility’s program statement must explain how compatibility is assured. [Wis. Admin. Code § DHS 83.06(1)(e)] AA – Advanced Age AODA – Alcohol / Drug Dependent CC – Correctional Clients DD – Developmentally Disabled (Intellectually Impaired) MH – Emotionally Disturbed / Mental Illness ALZ – Irreversible Dementia / Alzheimer’s PD – Physically Disabled PWC – Pregnant Women Who Need Counseling TI – Terminally Ill TBI – Traumatic Brain Injury Will you accept public funding? Yes No To be eligible to receive public funding, facilities must demonstrate compliance with The Centers for Medicare & Medicaid Services (CMS) Home and Community-Based Services (HCBS) settings rule during the onsite survey. Review the additional requirements listed on page 5 of this application. List any days and hours when residents are not usually in the facility. Days Hours Indicate the minimum and maximum monthly fees charged for resident care. If you charge the same fee to all residents, indicate the amount as your maximum rate. Minimum Monthly Rate Per Individual Maximum Monthly Rate Per Individual
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