Licensure & Certification Application



State of Wyoming–Department of Health Ph: 307-777-7123

Aging Division Fax: 307-777-7127

Healthcare Licensing and Surveys Web:

Hathaway Bldg., Suite 510 Email: wdh-ohls@

2300 Capitol Avenue

Cheyenne WY 82002

HOSPICE FACILITY

LICENSE APPLICATION FOR

ANNUAL RENEWAL

|Fees: |Annual Renewal |This application is not to be used for a new |

| | |provider, change in ownership, or other changes; they|

| |$100 |are to be submitted on a separate application form. |

|Make Payment to: Treasurer, State of Wyoming |

|FOR HLS USE ONLY |

|Fee Paid |Appl Approved |

|Check # | |

If we have questions/concerns, regarding the information provided on this application, whom should we contact?

Contact Person’s Name:     Email:      

GENERAL APPLICATION INFORMATION (This is a fillable form. Tab through the document to advance.)

1. Facility Name:

     

NOTE: Hereafter, “facility” will refer to the entity identified in #1.

2. Phone:      

3. Email:      

4. Name of Director:      

5. Provide services for: Outpatient only Inpatient only Both in/outpatient

6. Total number of beds to be licensed (inpatient):      

FACILITY NAME:

7. Services offered: (directly or under arrangement) (Check as appropriate)

Nursing Services Physician Services

Medical Social Services Homemaker Services

Hospice Aide PT

OT Speech

Counseling Services (including but not limited to: bereavement, spiritual, dietary)

Volunteer Services

Other:      

8. Number of Ancillary Locations:      

9. Owner and Operator – Are the owners and operators the same as those listed on the current license?

Yes No

If no, complete the Initial or Change in Ownership License Application form.

SIGNATURE

I acknowledge the Wyoming Department of Health will be immediately contacted if there is a change in ownership, facility name, address or location, number of licensed beds, or services provided.  I further acknowledge the facility is responsible for admitting and retaining only those individuals who qualify for this category of healthcare facility as defined in the applicable rule and facility policies and procedures

The facility agrees to allow authorized representatives of the Wyoming Department of Health, upon presentation of proper identification, to enter the facility at any time without a warrant, provide access to any facility records and documentation as deemed necessary to ascertain compliance with State licensing laws and rules promulgated by the Wyoming Department of Health.  My signature legally binds the facility’s agreement to abide by the rules promulgated by the State of Wyoming for this category of healthcare facility and I do hereby verify the information provided on this application is true to the best of my knowledge and belief. 

 

Application must be signed.  This can be an Administrator/Director, CEO, CFO, Executive Director, or Owner. 

Signature: _____________________________________________________________________________________

Printed Name:      

Title:      

Date:      

HOSPICE FACILITY

LICENSE APPLICATION INSTRUCTIONS

FOR ANNUAL RENEWAL

Important Information:

• The renewal application is a Word fillable form and must be used in print layout view. Tab through the application form to advance in the document.

• Each facility type must be submitted on the appropriate renewal application.

• Payment is still required to be in the form of a check make payable to: Treasurer, State of Wyoming.

o Please ensure the check clearly identifies the facility name in #1 of the renewal application in order for payment to be credited to the proper provider. Each renewal application requires a separate check.

• Renewal applications need to be submitted by Email; submission of hard copies are not needed. When Emailing please use the following subject line:

License Renewal – ABC Care Center [facility name]

• Renewal applications can be signed by the Administrator/Director, CEO, CFO or an Owner.

• Submission of an original signature page is not needed.

For further questions regarding the renewal application process, contact HLS by sending a detailed email (include facility name and facility type) to: wdh-ohls@ or tammy.schmitt@

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