Wisconsin 1-2 Bed Adult Family Home Certification Application



DEPARTMENT OF HEALTH SERVICESDivision of Medicaid ServicesF-02601 (06/2022)STATE OF WISCONSINWISCONSIN 1-2 BED ADULT FAMILY HOME (AFH) APPLICATIONINSTRUCTIONS:Completion of this form is not required through Wisconsin State Statute; however, completion of this form is required for certification and recertification as a 1-2 bed adult family home. Applicants will not be considered as certified until all necessary paperwork is completed, submitted, verified, and approved.Personally identifiable information on this form is collected to verify that the application is complete and accurate and will be used only for this purpose. FORMCHECKBOX Initial Application: First time certification as a 1-2 bed adult family home with the State of Wisconsin. Must complete the entire application. FORMCHECKBOX Recertification: For recertification, provider must complete Sections A - C, E, F, H, I, and J as well as submit all required documentation listed on the attached Documentation Checklist.SECTION A: DEMOGRAPHICSApplicant 1Last NameFirst NameMIMaiden Name or AKA FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Date of BirthSSNDriver’s License NumberFax FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Marital StatusHome Phone FORMCHECKBOX Single FORMCHECKBOX Married FORMCHECKBOX Divorced FORMCHECKBOX Widowed FORMTEXT ?????Street AddressCity, State, Zip Code FORMTEXT ????? FORMTEXT ?????Email Address FORMTEXT ?????Highest Level of EducationName of College/Area of Study FORMCHECKBOX High School FORMCHECKBOX Technical School FORMCHECKBOX College Degree FORMTEXT ?????Employer NameYour Job Title FORMTEXT ????? FORMTEXT ?????Work PhoneMay we call you at work?What hours do you work?Best time to call? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ?????Applicant 2Last NameFirst NameMIMaiden Name or AKA FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Date of BirthSSNDriver’s License NumberFax FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Marital StatusHome Phone FORMCHECKBOX Single FORMCHECKBOX Married FORMCHECKBOX Divorced FORMCHECKBOX Widowed FORMTEXT ?????Street AddressCity, State, Zip Code FORMTEXT ????? FORMTEXT ?????Email Address FORMTEXT ?????Highest Level of EducationName of College/Area of Study FORMCHECKBOX High School FORMCHECKBOX Technical School FORMCHECKBOX College Degree FORMTEXT ?????Employer NameYour Job Title FORMTEXT ????? FORMTEXT ?????Work PhoneMay we call you at work?What hours do you work?Best time to call? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ?????Name of AFHEmployer ID Number (EIN) FORMTEXT ????? FORMTEXT ?????Street AddressCityStateZip Code FORMTEXT ????? FORMTEXT ?????WI FORMTEXT ?????County NameTownship or VillageAFH Phone Number FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Does GPS find your home?Color of HomeOutside Covering: FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMCHECKBOX Siding FORMCHECKBOX BrickLocated on what side of the road: (Check one) FORMCHECKBOX North FORMCHECKBOX South FORMCHECKBOX East FORMCHECKBOX WestDirections to Home FORMTEXT ?????SECTION B: OTHER HOUSEHOLD MEMBERSName (oldest first)Date of BirthSexLiving in Home1. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Yes FORMCHECKBOX No2. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Yes FORMCHECKBOX No3. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Yes FORMCHECKBOX No4. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Yes FORMCHECKBOX NoOther Persons Who are Frequent Visitors of the HomeName (oldest first)Date of BirthSexLiving in Home1. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Yes FORMCHECKBOX No2. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Yes FORMCHECKBOX NoSECTION C: DESCRIPTION OF THE HOMELocation DescriptionNearest Town/ Distance from AFHNumber of Years at this Address FORMCHECKBOX City FORMCHECKBOX Rural FORMCHECKBOX Farm FORMTEXT ????? FORMTEXT ?????Do you own or rent?Previous Address FORMCHECKBOX Own FORMCHECKBOX Rent FORMTEXT ?????If renting, must submit copy of lease with this application.Type of AFH (See Article 1.C of the Wisconsin 1-2 Bed AFH Standards (P-00638) FORMCHECKBOX Traditional AFH FORMCHECKBOX Community Care HomeType of HomeIf a house, how many stories?If an apartment, what floor is it on? FORMCHECKBOX House FORMCHECKBOX Apartment FORMCHECKBOX Mobile Home FORMCHECKBOX One FORMCHECKBOX Two FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX One FORMCHECKBOX Two FORMCHECKBOX Other: FORMTEXT ?????How is water supplied to your home?Is your home wheelchair accessible? FORMCHECKBOX Public Water Supply FORMCHECKBOX Private Well (testing required) FORMCHECKBOX Yes FORMCHECKBOX NoNumber of BedroomsNumber of BathroomsFirst FloorSecond FloorOtherFirst FloorSecond FloorOther FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????How many rooms are in the home (to include bath, bedroom, and laundry rooms)? FORMTEXT ?????Describe any other special adaptations in your home (ramps, grab bars; wide doorways; lifts; etc.) FORMTEXT ?????Can the bathroom door be locked to allow for privacy? FORMCHECKBOX Yes FORMCHECKBOX NoAre there pets in your home that do not belong to member(s)?Are members allowed to keep pets in the home? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoType of PetExpiration Date(s) of Vaccine1. FORMTEXT ????? FORMTEXT ?????2. FORMTEXT ????? FORMTEXT ?????3. FORMTEXT ????? FORMTEXT ?????Information about Available TransportationDoes the AFH intend to offer transportation to persons served by the AFH?Is your vehicle handicap accessible? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoList other persons in the household with a valid driver’s license who are willing to provide transportation. Include valid Driver’s License number for each person listed below. 1. Name: FORMTEXT ?????Driver’s License Number: FORMTEXT ?????2. Name: FORMTEXT ?????Driver’s License Number: FORMTEXT ?????3. Name: FORMTEXT ?????Driver’s License Number: FORMTEXT ?????Do you use your home for business purposes or provide other services within your home? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe: FORMTEXT ?????Please describe the layout of your home in the space provided below. If you require additional space beyond what is provided below, the information can be submitted on a separate document to be attached to the completed application. FORMTEXT ?????SECTION D: PRIOR EXPERIENCEAre you applying to provide care for a specific person? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, relationship to person? FORMTEXT ?????Have you provided care for adults in your home previously?Applicant 1. FORMCHECKBOX Yes FORMCHECKBOX NoWhen? FORMTEXT ????? If yes, was your home licensed or certified by the Wisconsin Department of Health Services (WI DHS) or any other entity? Please specify: FORMTEXT ?????Applicant 2. FORMCHECKBOX Yes FORMCHECKBOX NoWhen? FORMTEXT ?????If yes, was your home licensed or certified by WI DHS or any other entity? Please specify: FORMTEXT ?????If no, how did you learn about our program? FORMTEXT ?????If you are currently licensed or certified by another entity other than WI DHS, please list the entity that completed your last certification and effective date. Please include copy of license or certification with this application. FORMTEXT ?????Note: You must submit a copy of your current license or certificate with your application.SECTION E: PRIOR EXPERIENCEWere you ever denied licensure or certification of any kind to provide care and services, or has such licensure or certification been revoked or suspended?Applicant 1. FORMCHECKBOX Yes FORMCHECKBOX NoWhen? FORMTEXT ?????If yes, please include the licensing or certifying agency, type of license or certificate, and a brief explanation of reason for revocation or suspension: FORMTEXT ?????Applicant 2. FORMCHECKBOX Yes FORMCHECKBOX NoWhen? FORMTEXT ?????If yes, please include the licensing or certifying agency, type of license or certificate and a brief explanation of reason for revocation or suspension: FORMTEXT ?????In the past two years, has either applicant experienced the denial of an original application for certification, denial of an application for recertification, or revocation of the existing certification or license of any residential or day service for adults or children from WI DHS or any other entity? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please include the name of the entity that issued the denial or revocation and a brief description of reason for the revocation or denial: FORMTEXT ?????SECTION F: PREFERENCEDo you want to be certified for one or two adults?What age group would you prefer to work with? FORMTEXT ????? FORMTEXT ?????Please select which population(s) for whom you would like to provide care: FORMCHECKBOX IDD FORMCHECKBOX Physically Disabled FORMCHECKBOX Frail EldersAre you interested in providing short-term (respite) care to one or more adult(s) in your home in addition to providing care for the long-term member(s)? FORMCHECKBOX Yes FORMCHECKBOX NoSECTION G: BACKGROUND CHECKSAs stated in Article IV.3 the Wisconsin Medicaid Standards for Certified 1-2 Bed Adult Family Homes (P-00638) all applicants, staff, substitute providers and household members 18 years of age and above must complete a caregiver and criminal background check completed at time of initial application and minimum of every 4 years thereafter. If you or your staff members/caregivers do not have a current background check on file, all applicable individuals must print and complete the Background Information Disclosure (F-82064) form and then submit the signed releases with your completed application.AFH providers are required to complete background checks for all of their own staff, caregivers and anyone 18 years or older living in the home. The Wisconsin DHS will only perform these checks on applicants including sponsor/ provider and operators. Single Subject or Multiple Subject requests may be submitted directly to the Department of Justice for any incomplete criminal background checks through the Wisconsin Department of Justice. Providers must ensure that they mark ‘Caregiver-General’ under the Request Purpose before submitting their payment and completed form. The Wisconsin DHS will require proof of completion of current background checks for all staff, caregivers, and persons 18 or older residing in the household. Information about the background check process can be accessed and downloaded at: SECTION H: REFERENCESList three (3) people who you know well, who may be contacted to provide a personal reference. Only one (1) reference may be a relative who is not also living with you in the AFH.1. NameRelationship FORMTEXT ????? FORMTEXT ?????Street AddressCityStateZip Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Phone NumberEmail FORMTEXT ????? FORMTEXT ?????2. NameRelationship FORMTEXT ????? FORMTEXT ?????Street AddressCityStateZip Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Phone NumberEmail FORMTEXT ????? FORMTEXT ?????3. NameRelationship FORMTEXT ????? FORMTEXT ?????Street AddressCityStateZip Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Phone NumberEmail FORMTEXT ????? FORMTEXT ?????SECTION I: FINANCIAL INFORMATIONMedical Assistance – Per Wisconsin State standards, AFH providers may be requested to present evidence of having or having access to sufficient financial reserves to meet the needs of all members and others living in the household for whom the provider is financially responsible and to ensure the adequate functioning of the home for a period of at least 30 days without receiving pay for the care of any members.Gross Family Income$ FORMTEXT ?????Net Family Income$ FORMTEXT ?????Sources of Income (wages, Social Security, interest, child support etc.) Do not list individual dollar amounts.1. FORMTEXT ?????2. FORMTEXT ?????3. FORMTEXT ?????SECTION J: ATTESTATION AND SIGNATURESThe applicant is responsible for notifying WI DHS, in writing, of any changes in the information in the application using the 1-2 Bed Adult Family Home (AFH) Change Reporting Form (F-03044). In completing this application, I (we) understand that there is no guarantee by the Wisconsin DHS that an adult will be placed in my (our) home. I (we) give permission to contact the references provided and in addition, obtain any medical, psychiatric, financial, criminal, and employment information needed to process this application. The Wisconsin DHS is free to verify any information on the application form and to contact other agencies, such as Human Service Departments and 51.42 Agencies. I (we) understand that the information disclosed will be used for the sole purpose of investigating my application for AFH certification.I (we) further attest that the information contained in this questionnaire is true, correct, and complete to the best of my (our) knowledge. SIGNATURE – Provider Applicant 1Date SignedSIGNATURE – Provider Applicant 2Date SignedFurther, I attest that I have read and will comply with all applicable requirements as stated in the Wisconsin Medicaid Standards for Certified 1-2 Bed Adult Family Homes (P-00638).SIGNATURE – Provider Applicant 1Date SignedSIGNATURE – Provider Applicant 2Date SignedSUBMISSION OF COMPLETED APPLICATIONThis application and all supportive documentation and/ or questions about the application and certification process must be submitted by email to: dhsirisafh@dhs.. Once the 1-2 Bed AFH Certification Team has reviewed your documentation, you will be contacted to schedule an onsite visit of your home. No home is eligible for certification or recertification unless an onsite visit has been conducted. The Wisconsin DHS reserves the right to substitute a virtual tour for an onsite tour at their sole discretion. Requests by providers to substitute a virtual visit for an onsite visit will not be approved. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download