Get Wi Dhs F-60287 2013-2026
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How to fill out the WI DHS F-60287 online
Filling out the WI DHS F-60287 form is an essential step in applying for a Community Based Residential Facility license. This guide provides a clear, step-by-step approach to ensure each component of the form is completed accurately and thoroughly.
Follow the steps to successfully complete the application.
- Click ‘Get Form’ button to obtain the form and open it for editing.
- Review the requirements listed at the beginning of the form. Ensure you have all required documentation ready for submission, including program statements and background checks.
- In Section I, General Information, fill in the facility name and address, including the city, state, and zip code. Provide telephone and fax numbers, as well as email addresses for both the facility and the administrator.
- Indicate the size of the Community Based Residential Facility by checking the appropriate box for small (5-8 residents), medium (9-20 residents), or large (21 or more residents). Also, specify the class/type of CBRF.
- Complete Section II regarding Resident Information. Provide the total capacity for residents and indicate primary client groups you intend to serve by checking the relevant boxes.
- For Section III, Financial Information, ensure that your submitted balance sheet accurately reflects monthly operating expenses and sources of income. Clearly state the minimum and maximum monthly fees charged for resident care.
- In Section IV, Fit and Qualified, answer the qualification questions honestly. If applicable, provide necessary details regarding prior licenses and any enforcement actions.
- Section V and VI inquire about ownership details. List all individuals or entities with ownership interests and supply any additional information required about financial interests.
- For Section VII, Creditors, provide the names and addresses of all creditors holding security interests in the facility, along with the extent of obligations.
- Finally, complete the attestation section at the end of the form. Sign the document and include the date, along with your printed name and title.
- After thoroughly reviewing your form for accuracy, save the changes. You can then download, print, or share the completed form as necessary.
Start filling out your application online today to secure your Community Based Residential Facility license.
To report a nursing home to the state of Wisconsin, you should complete the WI DHS F-60287 form available on the Wisconsin Department of Health Services website. This form allows you to detail the concerns or issues you’ve observed regarding the care provided at the facility. After submitting the form, the WI DHS will review your report and take appropriate action. Your proactive approach helps maintain standards in nursing homes across the state.