Dhs f 62548 2009 form-2026

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The document is a form from the Wisconsin Department of Health Services for assisted living facilities to request waivers, approvals, variances, or exceptions. It outlines the voluntary nature of form completion, the use of personal information during the review process, and provides instructions for submission to the appropriate regional office. The form requires details about the facility, resident, existing conditions, and alternate proposals.

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Click ‘Get Form’ to open the dhs f 62548 2009 form in the editor.
Begin by entering the facility name and checking the type of facility (CBRF or AFH). Fill in the address details including street, city, state, and zip code.
Next, provide the resident's name and license number. Ensure all information is accurate for a smooth review process.
In the 'Describe existing condition' section, clearly outline the current situation that necessitates this request.
If applicable, detail your alternate proposal for variance on additional pages and attach them as needed.
Complete the 'Name - Person Completing This Form' section by printing or typing your name and title. Specify the time period this request covers by filling in the 'From' and 'To' dates.
Finally, sign and date the form before submitting it to the appropriate DQA Regional Office.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (203 Votes)
2016	4.3 Satisfied (65 Votes)
2015	4.4 Satisfied (280 Votes)
2009	4 Satisfied (42 Votes)

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