Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the Name of the Facility in the designated field.
3. Select the Type of Facility from the options provided (ADC, AFH, CBRF, RCAC).
4. Fill in the City's name and the facility's Street Address.
5. Choose the Type of Request by selecting Waiver, Approval, Variance, or Exception.
6. Input the License Number in the specified area.
7. Enter the County and Zip Code of the facility.
8. Indicate the Time Period of Request by checking either Permanent or Temporary. If Temporary, provide the start and end dates (MM/dd/yyyy).
9. If applicable, input the Name of the Resident.
10. Complete the Applicable Codes section when relevant.
11. Answer whether the resident is a Family Care or IRIS member by selecting Yes or No. If 'Yes,' provide the Name of the Case Manager.
12. Provide the Specific Action Requested in clear terms.
13. Describe the Steps Facility Will Implement to Ensure Resident Safety.
14. If the request involves a restraint device, describe other alternatives attempted and attach any relevant assessments if needed.
15. Fill in the Name, Email Address, and Telephone Number of the person completing the form.
16. Provide the Signature of the Person Completing the Form along with their Title.
17. Input the Date Signed in the specified format (MM/dd/yyyy).
18. After reviewing all entries, save changes, download, print, or share the completed form.

Complete your WI DHS F-62548 form online today!