
DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-00191 (11/09) STATE OF WISCONSIN Page 1 of 2 CERTIFIED OUTPATIENT CLINIC REQUEST FOR A BRANCH OFFICE See Division of Quality Assurance.
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How to fill out the Dqa Form F 00191 online
Filling out the Dqa Form F 00191 is an essential step for certified outpatient clinics seeking to request a branch office. This guide provides clear instructions to help users complete the form accurately and efficiently in an online format.
Follow the steps to complete the Dqa Form F 00191 online.
- Click the ‘Get Form’ button to access the Dqa Form F 00191 and open it in your online document editor.
- Fill in your certification number at the specified section. This is essential for identifying your main clinic.
- Enter the email address of the contact person for your clinic. Ensure that this email is active for future communication.
- Indicate the intensity and type of clinic, selecting options such as mental health, AODA, or both.
- List the days and hours of operation for psychotherapy or substance abuse counseling at the branch office.
- Answer whether consumer records are kept at the branch office and describe how the records are stored if applicable.
- Finally, attest to the accuracy of the information provided by signing the form as the clinic administrator, and include your printed name and the date signed.
- Once all sections are complete, save the changes and choose to download, print, or share the form as needed.
Complete your Dqa Form F 00191 online today to ensure your clinic can effectively serve its clients through a branch office!
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