NOTE TO APPLICANTS: Initial Surveys for Medicare Participation: S&C Memo 08-03: Initial Surveys for New Medicare Providers
The following information can be accessed on the Licensure and Medicare/Medicaid Certification for Hospitals web pages:
- Caregiver Background Check Information
- Licensure Application
- Initial Licensure Review Process
- Medicare Certification Application Process
- Completion of Forms
- Full Operation Letter
- Medicare Certification Survey Process
- Certification Denial
- Certification with the Wis. Medical Assistance (Medicaid) Program (WMAP)
- Chapter DHS 124 - Wisconsin Administrative Code + Appendix - Scroll down to DHS 124
Chapter 50 - Uniform Licensure - Search for Chapter 50
Forms and Documents
The following forms and documents can be located on the web sites listed below.
The applicant will need to complete the Hospital Certificate of Approval Application along with the following forms and send to the Bureau of Health Services, Division of Quality Assurance.
- Chapter DHS 124 - Hospital Certificate of Approval Application DQA F-62092 (PDF, 524 KB)
- Chapter DHS 124 - Hospital Certificate of Approval Application DQA F-62092 (Word, 748 KB)
- Use either of these two forms as you see appropriate. The PDF version can be filled out online, but not saved, unless you have a complete Adobe Acrobat program (not just Adobe Reader).
- F-82064 - Background Information Disclosure Form (PDF, 30 KB)
- F-82069 - Background Information Disclosure Appendix Form (PDF, 31 KB)
- Conditions of Participation for Hospitals
Data Request Checklist-Civil Rights Information Request
HHS 690- Assurance of Compliance form (two signed copies if completing hard copies)
CMS 1561 - Health Insurance Benefit Agreement (scroll down past "search for a form") - 2 originals must be signed and returned
NOTE: Before the start of any construction or remodeling project, plans for the construction or remodeling must be submitted to the department, pursuant to s. DHS 124.29, for review and approval by the department (refer to Subchapter V - Physical Environment, DHS 124, Wisconsin Administrative Code).
For more information regarding physical environment, contact the Bureau of Health Services, Division of Quality Assurance, at 608-264-7748 or see Plan Review website.
Under Chapter 50 of the Wisconsin Statutes [s.50.065] the department is required to perform background checks on license holders/applicants, non-clients who reside at the entity, and on employees/staff.
Where the applicant is a corporation or other similar legal body, the applicant must identify by name the other members of the corporation or other legal body, in addition to the signatories on the application, who legally make up the body to which a license or certification or other such similar regulatory approval is issued.
The applicant shall designate for each, who will or will not have access to clients the entity serves. The department will do background checks on all signatories on the application, and on the other members identified on the application.
Background Information Disclosure (BID) Form (F-82064)
The BID form gathers information as required by the Wisconsin Caregiver Background Check Law to help employers and governmental regulatory agencies make hiring, licensing, certification or registration decisions.
Refer to the Caregiver Background Check Process web page for information for completing the BID form for Licensee Applicants/License Holder Background Checks.
Also review information on the requirement for Employee Background Checks found on the Caregiver Background Check Process web page.
A. Complete application packet. Make sure application is signed. Submit completed application to:
Division of Quality Assurance
Bureau of Health Services
P.O. Box 2969,
1 W. Wilson St. Rm. 455
Madison, WI 53701-2969
B. Chapter 50 of the Wisconsin Statutes [s.50.135(2)(a)] requires that the fee for an inpatient health care facility except a nursing home is $18.00 per bed.
C. Wisconsin Administrative Code, Chapter DHS 124, General and Special Hospitals, sets forth certain minimum requirements to be met. In order that we have a complete application, please submit the following supplemental information:
1. Copy of the hospital articles of incorporation, and the bylaws written in accordance with DHS 124.05.
2. Medical staff bylaws including the various committees. For information of what the bylaws shall include, please refer to Subchapter III, DHS 124.12(5)(b). Please also provide the names of the active physician staff.
3. Written policies established by governing board on patients rights and responsibilities. (DHS 124.05(3)).
4. The name and qualifications of the registered nurse who will direct the nursing service and the designee. (DHS 124.13)
5. The registered nurse staff pattern for 24-hour registered nurse coverage seven days per week, including names and registration number. (DHS 124.13)
6. The name of the qualified medical record administrator or accredited record technician and the number of hours on duty. (DHS 124.14)
7. The name of the staff or consulting pharmacist who will direct the pharmacy or drug room and the number of hours on duty. (DHS 124.15)
8. The name and qualifications of the registered dietitian who will direct the dietary service, including the number of hours on duty. (DHS 124.16)
9. Names of staff pathologist and hours on duty, or name of qualified physician, or name and qualifications of laboratory specialist. (DHS 124.17)
10. Policies and procedures governing medical care provided in the emergency service. (DHS 124.24)
11. The name and qualifications of the social worker who will direct the social work service and the number of hours on duty. (DHS 124.25)
12. Provide schematic plans, which shall include at least the following adjunct service facilities:
a. a clinical laboratory
b. a blood bank
c. diagnostic x-ray facilities available in the hospital building proper or in an adjacent clinic or medical facility that is readily accessible to the hospital patients, physicians and personnel
d. a medical library
13. If the hospital will be classified as a special hospital that primarily provides psychiatric care to inpatients and outpatients, the following additional requirements need to be submitted:
a. Medical record policies documenting the degree and intensity of the treatment provided to individuals who are furnished services.
b. Documentation regarding treatment plans and staffing that meets the requirements in DHS 124.26(3).
For assistance in completing forms for hospital licensure and certification, please call Hospital Licensing Specialist at 608-266-7297. Questions regarding the Conditions of Participation survey process should be directed to the Bureau of Health Services at 608-266-7881.