State of Wyoming– Department of Health Ph: 307-777-7123
Aging Division Fax: 307-777-7127
Healthcare Licensing and Surveys Web: https://www.health.wyo.gov/aging/hls
Hathaway Bldg, Suite 510 Email: tammy.schmitt@wyo.gov
2300 Capitol Avenue
Cheyenne WY 82002
ADULT FOSTER CARE HOME
LICENSE APPLICATION
Fees: Initials, Change in Ownership, Annual Renewal
(Anything marked in 1a thru 1c below)
$100 Changes
(Anything marked in 1d thru 1e below)
$50
Make Payment to: Treasurer, State of Wyoming
FOR HLS USE ONLY
Fee Paid Old # Appl Approved
Check # New #
If we have questions/concerns regarding the information provided on this application, whom should we contact?
Contact Person’s Name: – FORMTEXT Email:
This is a fillable form. You must tab through the document to advance. Please read the
License Application Instructions prior to completing this application.
(Licenses will NOT be sent in hard copy but sent electronically via Email to the address in #9 below.)
GENERAL APPLICATION INFORMATION
Type of Application: (check one)
Initial Application
Change in Ownership Effective Date of Change:
– FORMCHECKBOX Annual Renewal
Changes: For any of the changes marked below, complete the entire application with all the new information.
Change in Address of Main Physical Location Effective Date of Change:
Old Address:
Change in Facility Name Effective Date of Change:
Old Name:
Facility Name: (This is how it will appear on your license. See specific details on the license application instructions.)
Physical Facility Full Address: (Main location. Include city, st., zip)
Mailing Address: (If different than #3. Include city, st., zip)
FACILITY NAME: – REF FACNAME \* MERGEFORMAT
County:
Fiscal Year End Date:
(See specific details on the license application instructions.)
Phone:
Fax:
9. Email:
(See specific details on the license application instructions.)
PROVIDER DETAILS
Federal Employer Tax ID (EIN) number:
(See specific details on the license application instructions.)
Does the Adult Foster Care Home have in place a documented quality management function to evaluate and improve resident client care and services? Yes No
Number of beds to be licensed:
PERSONNEL
Name of Manager:
Name of Supervising Nurse:
RN License Number:
LOCATIONS/BUILDINGS (You must attach a readable and clear floor. See specific details on the license application instructions.)
Main Building Location
Property Ownership: – FORMCHECKBOX Own Rent Lease
Physical Address: (Include city.)
Services at this location:
Date services began at this location:
Is there a current construction or remodel project going on at this location? Yes No
If yes, list HLS project numbers:
FACILITY NAME:
OWNER/OPERATOR
Ownership type: (check one)
(See specific details on the license application instructions.)
Sole Proprietor/Individual
Partnership
Profit Corporation
Nonprofit Corporation
Limited Liability Company
Governmental: City County Hospital District State
Other: – FORMTEXT
Ownership Name:
Mailing Address:
Phone:
Contact Person:
Contact Person’s Email:
22. List all officers in the ownership and titles below: or List attached.
(This is the Pres, VP, etc. or Board Members; not the CEO, CFO, etc. See specific details on the license application instructions.)
a.
b.
c.
d. – FORMTEXT
e.
Has the owner ever had a license to operate a healthcare facility or agency providing healthcare services in this or any other state denied, suspended, revoked or otherwise terminated for cause? Yes No
If yes, explain:
FACILITY NAME:
Is the Adult Foster Care Home operated or managed by a business entity other than the owner listed in #17 above?
Yes No
If yes, Operating Entity Name:
Mailing Address:
Phone:
Contact Person’s Name:
Contact Person’s Email:
Has the operator ever had a license to operate a healthcare facility or agency providing healthcare services in this or any other state denied, suspended, revoked or otherwise terminated for cause? Yes No
If yes, explain:
Did you read and understand the healthcare facility licensure requirements (W.S. 35-2-901 and 902 et seq) outlined in the license application instructions? Yes No
FACILITY NAME:
SIGNATURE
Wyoming Statutes requires signature by two (2) officers of the organization, or a signature of all managing agents. If signed by managing agents, copies must be attached of company documents indicating the individuals signing are managing agents for the company.
I have read the contents of this application. My signature legally binds the facility’s agreement to abide by the rules promulgated by the Stat of Wyoming for this category of healthcare facility and do hereby state the information provided on this application is true to the best of my knowledge and belief.
The facility further understands the facility is responsible for admitting and retaining only those persons who qualify for this category of healthcare facility as defined in the applicable rule and facility policies and procedures. The facility agrees to allow authorized representative of the Wyoming Department of Health, upon presentation of proper identification, to request and/or enter the facility at any time without a warrant, any facility records and documentation as necessary to ascertain compliance with State licensing laws and rules promulgated by the Wyoming Department of Health.
Application must have original signatures of two officers as listed in the ownership section above. In most cases, a CEO, CFO, Administrator, or Director signature will not be accepted.
Signature #1_____________________________________________________________________________________
Printed Name:
Title:
Date:
Signature #2_____________________________________________________________________________________
Printed Name:
Title:
Date:
Rev. 03/15/2019 Page 1 of 5
Rev. 03/15/2019 Adult Foster Care Home License Application Page 5 of 5
Document checksum: 2288313346
Document converted by WebSite-Watcher.
(Plugin #1/1.38/3.0.24/1.0)