Get Mi Bhcs-ltc-101 2013-2025

The MI BHCS-LTC-101 is an essential application for obtaining or renewing a nursing home license in Michigan. Understanding how to accurately complete this form is crucial for a smooth application process.

Follow the steps to successfully complete the MI BHCS-LTC-101 form online.

1. Click the ‘Get Form’ button to access the MI BHCS-LTC-101 document and open it for editing.
2. Select whether you are submitting an initial license application, renewal application, or a change of ownership application by checking the appropriate box.
3. Fill out the facility information section by providing the facility name (D.B.A.), address, state facility number, CMS certification number, county, city, phone number, and fax number.
4. Indicate the primary contact person for the facility and provide their phone number as well as the name and phone number for the emergency contact.
5. List the MDS assessment contact person along with their phone number.
6. Enter the NPI number(s), attaching a separate sheet if necessary, and fill in details about the licensed administrator, including their name, email address, license number, license expiration date, and date of hire.
7. Indicate the employment status of the licensed administrator (full-time, part-time, or contract) and provide the name of any other facility where they are employed if applicable.
8. Complete the details for the licensed director of nursing by providing their name, license number, expiration date, and date of hire.
9. If applying for licensure and certification, complete the fiscal intermediary section with the intermediary name, number, and address.
10. Fill out the bed information section, including current and requested beds, as well as information regarding special pool beds.
11. Provide ownership information, including the legal entity that owns the facility, their contact details, tax ID, and whether the ownership is for profit or non-profit.
12. List the officers, directors, and trustees by providing their names, positions, contact information, and tenure.
13. Indicate whether any individuals listed have been convicted of a criminal offense and if they have interests in other healthcare facilities by answering the respective questions.
14. Include details about the building owner and lien holder, and if there's a management company, provide their contact information.
15. If requesting an initial license or change of ownership, complete the estimated monthly revenues/expenditures and provide a list of suppliers.
16. Review the certification section and sign the application, providing your title and date.
17. Save changes, download, print, or share the completed form as necessary once all sections are filled out.

Complete your MI BHCS-LTC-101 application online today for a smooth licensing process!