LICENSE APPLICATION INSTRUCTIONS
Important Information:
The application is a Word fillable form and must be in print layout view. You must tab through the form to advance in the document.
All sections of the application must be completed, regardless of the type of application.
An application for each facility must be submitted separately.
Only checks are accepted for payment. Please make payable to:
Treasurer, State of Wyoming.
Applications can be mailed to the address on the top of the application OR it may be emailed to: tammy.schmitt@wyo.gov
IF MAILED:
If you mail the application instead of sending via email, ensure it is a complete application (all sections are completed, signatures, attachments and fee) and all documentation comes in together.
IF EMAILED:
If emailed, please use the subject line: License Application Submission
If emailed, ensure all appropriate attachments are included in the email. An original signature page (no copies) along with the appropriate fee must still be mailed in. Only send the signature page, DO NOT send a hard copy of the entire application, this may cause delays because we will need to review the hard copy to ensure nothing has changed from the emailed copy.
Please ensure the signature page (with facility name at the top) and check are sent in together so payment can be easily matched up to the right provider. A check must be submitted with EACH application.
General Information:
Based on the healthcare facility type, some of these areas are not applicable on all license applications.
Type of Application –
Initial Application – This is for a brand new facility
Change in Ownership – This is when an existing facility is changing ownership. Licenses are not transferrable. A change in ownership is processed the same way an initial application is processed.
Annual Renewal – This is for the annual renewal which is usually conducted sometime between March and June each year.
Changes – These areas are self-explanatory and are for changes that an existing license facility would like to make.
Contact person – This is the person Healthcare Licensing and Surveys (HLS) will contact if there are any concerns or questions upon review of the license application. Communication will be sent via e-mail to this person.
Facility name – This is how the facility’s name will appear on the license. If the facility is a Medicare/Medicaid certified provider, the name here should match the name in which the CMS Certification Number (CCN) and provider agreement are filed under.
Physical address – This is the main physical location where the facility being licensed is located.
Mailing address – This is the address that will be used to send any hard copy correspondence.
Fiscal year end date – This is the date marking the end of the facility’s fiscal year for purposes of financial reporting and Medicare/Medicaid reporting.
Phone – This is the phone number of the actual facility. This is the number HLS will use when needing to reach the facility administrator or other staff. This will also be the number listed in the public HLS Facility Directory on our web page, for consumers wanting to reach the provider.
E-mail – This is the e-mail address HLS will use for official correspondence, notices, and most importantly the survey results. Only one e-mail can be used, so please ensure this is an e-mail that will be maintained and monitored closely. Centers for Medicare and Medicaid Services (CMS) will also use this e-mail address for their correspondences. Also, please be aware that e-mails will be sent encrypted and secure. We recommend this be someone directly at the facility verses a corporate address.
NOTE: For Nursing Homes the surveys will be sent via the new ePOC process. Please ensure you have at least two ePOC users signed up and that their account remains active. Guidance is on our webpage at https://health.wyo.gov/aging/hls/facility-types/nursing-care-facility-nursing-home-wyoming-licensure-information/
CMS Certification Number (CCN) – This is the number CMS assigned to the facility upon initial certification and is used to track certification of the provider agreement between CMS and the provider. The number will start with a 53.
National Provider Identify Number (NPI) – This is the standard unique health identifier for health care providers adopted by the Secretary of Health and Human Services in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). All individuals and organizations who meet the definition of health care provider as described at 45 CFR 160.103 are eligible to obtain an NPI. If you are a HIPAA covered provider or if you are a health care provider/supplier who bills Medicare for your services, you need an NPI.
Employer Tax ID # (EIN) – This is also known as a Federal Tax Identification Number, and is used by the IRS to identify the taxpayer. EINs must be used by business entities--corporations, partnerships, and limited liability companies. However, most sole proprietors don't need to obtain an EIN and can use their Social Security numbers instead.
Fidelity bond – A fidelity bond guarantees performance of a certain act (trustworthiness of employees). You can file a claim against a bond like you would an insurance policy. A bond doesn’t have a deductible where as an insurance policy does, and the concern with an insurance policy would be if the provider would have the capability of covering the expenses to the deductible amount. The rules and regulations specifically state a fidelity bond.
Provider-based – This is an entity that furnishes services that are integrated with another entity as the main provider, such as a hospital for one example. For CMS certification all provider-based requirements and approval must be met to obtain such status.
Free-standing – This is an entity that is not integrated with any other entity as a main provider and operates independently.
Geographic Service Area – This is the location(s) served by the home health agency or hospice provider. This is defined by either entire counties, by cities/towns, or by zip code areas, and must be listed as such on the license application. For CMS certified providers this service area is also defined when submitting a CMS Application (855) to the Medicare program. The geographic service area must be the same for licensure and certification. You must also include a map clearly identifying the geographic service with the license application. If you wish to expand or decrease your geographic service area, please contact HLS for further information.
Provider Transaction Access Number (PTAN) – This is the number that will be issued upon application (CMS-855) to a Medicare Administrative Contractor (MAC). While only the NPI can be submitted on claims, the PTAN is a critical number directly linked to the provider or supplier’s NPI. The NPI and the PTAN are related to each other for Medicare purposes. A provider must have one NPI and will have one, or more, PTAN(s) related to it in the Medicare system, representing the provider’s enrollment. If the provider has relationships with one or more medical groups or practices or with multiple Medicare contractors, separate PTANS are generally assigned. All providers and suppliers should carefully review their Provider Enrollment and Chain/Ownership System (PECOS) records in order to protect themselves and their practices from identity theft. PECOS is an online Medicare enrollment system where providers and suppliers can submit, view, update, etc. Medicare enrollment applications. PECOS should only contain active enrollment records that reflect current practice and group affiliations.
Admission & Occupancy Data – This information is only required on annual renewal applications. Instructions for calculation are included at the end of these instructions.
Deemed Status – Medicare-participating healthcare providers and suppliers are surveyed either by State Survey Agencies or by Accrediting Organizations (AOs) to ensure that they meet CMS’ quality and safety standards. AOs receive deeming authority from CMS, which affirms that AOs’ health and safety standards meet or exceeds those of Medicare. Deemed status is voluntary, meaning a provider could belong to an AO and not be deemed. To obtain deemed status the provider must request and receive approval from CMS to accept the AO’s survey process instead of using the State Survey Agency for provider certification survey. If you do have deemed status you must send a copy of the most recent accrediting survey and any subsequent surveys; do not send a copy of your State survey. If you are not a deemed provider, no survey documents need to be submitted.
Accrediting Organization (AO) Acronyms:
TJC – The Joint Commission
AAAHC – Accreditation Association for Ambulatory Health Care
ACHC – Accreditation Commission for Health Care, Inc.
AAAASF – American Association for Accreditation of Ambulatory Surgery Facilities, Inc.
HFAP – American Osteopathic Association/Healthcare Facilities Accrediting Program
CIHQ – Center for Improvement in Healthcare Quality
CHAP – Community Health Accreditation Partner
DNV – DNV Healthcare (Det Norske Veritas)
IMQ – Institute for Medical Quality
NDAC – National Dialysis Accreditation Commission
TJC – The Joint Commission
The HLS website has contact information for the AOs at: https://health.wyo.gov/aging/hls/forms-and-policies
Name/Title of Person in Charge of Facility – Depending on the facility organizational structure, this could be the CEO, etc. or it could be the same person listed in the Administrator/Director section.
Facility Floor Plan – A readable and clear copy of the floor plan is required and must identify resident/patient with room numbers; as well as other service areas such as dining room, activity area, shower/tub room, toilet rooms, utility rooms, dietary services, etc. For an Assisted Living Facility, you must also indicate what rooms are Level I and Level II. Please ensure the name of the facility is identified on the plan.
Owner – This is not the owner of the physical structure. This is the entity who will be the governing authority and have legal control of the facility. This entity usually has ownership interest in the facility’s share of profits and losses or similar items and the right to receive distributions.
Officers – Dependent on the ownership type, this is either the name of the sole proprietor, names of the partners, names of board members, or names of individuals that are officers of the corporation, etc. This is not the CEO, CFO, Administrator, etc. as they are usually appointed, elected or hired by the owners.
Operator – This is the entity who will be responsible for the operation of the facility for the owner. Usually under some form of contract or management agreement with the Owner. This entity will act on behalf of the Owner in the overall management, responsibility, and day-to-day operations of the facility.
Please see the following pages with Admission & Occupancy calculations (page 6) and healthcare facility licensure requirements (page 7) at W.S. 35-2-901 and 902 et seq as referenced on the license application.
Please find the Attestation Form (last page) at the end of these instructions. Please submit one for each ancillary location as identified in the Building Location section of the license application.
For further questions regarding the application process, the best method to contact HLS is by sending a detailed e-mail (include facility name and facility type) to: tammy.schmitt@wyo.gov
If at any time during the licensure period there is a change in Administrator/Director, Director of Nursing/Nursing Supervisor or the main contact e-mail, please complete a Facility Change Form and submit it to our office. This form is located at: https://health.wyo.gov/aging/hls/forms-and-policies/
ADMISSION AND OCCUPANCY CALCUATIONS
OCCUPANCY RATE % EXAMPLE
(April 1 – March 31)
x = Determine Actual Total Resident Days of Care Add up the total daily census for the year.
Apr 1 = 10; Apr 2 = 15; Apr 3 = 15, etc. TOTAL = x
y = Determine Available Total Residents Days of Care Take the number of licensed beds X number of days in calendar year
105 lic beds x 365 days = y
z = Determine Occupancy Rate Percentage Actual Total Resident Days of Care ÷ Available Total Residents Days of Care
x ÷ y = z
EXAMPLE: x = 34,659 days (10+15+15+etc.)
y = 38,325 days (105 x 365)
z = 90% (34,659 ÷ 38,325)
HEALTHCARE FACILITY LICENSURE REQUIREMENTS
wyoming state statute
TITLE 35 / PUBLIC HEALTH AND SAFETY
CHAPTER 2 / HOSPITALS, HEALTH CARE FACILITIES AND HEALTH SERVICES
ARTICLE 9 / LICENSING AND OPERATIONS
35 2 901. Definitions; applicability of provisions.
(a) As used in this act:
(i) "Acute care" means short term care provided in a hospital;
(ii) "Ambulatory surgical center" means a facility which provides surgical treatment to patients not requiring hospitalization and is not part of a hospital or offices of private physicians, dentists or podiatrists;
(iii) "Birthing center" means a facility which operates for the primary purpose of performing deliveries and is not part of a hospital;
(iv) "Boarding home" means a dwelling or rooming house operated by any person, firm or corporation engaged in the business of operating a home for the purpose of letting rooms for rent and providing meals and personal daily living care, but not habilitative or nursing care, for persons not related to the owner. Boarding home does not include a lodging facility or an apartment in which only room and board is provided;
(v) "Construction area" means thirty (30) highway miles, from any existing nursing care facility or hospital with swing beds to the site of the proposed nursing care facility, as determined by utilizing the state map prepared by the Wyoming department of transportation;
(vi) "Department" means the department of health;
(vii) "Division" means the designated division within the department of health;
(viii) "Freestanding diagnostic testing center" means a mobile or permanent facility which provides diagnostic testing but not treatment and is not part of the private offices of health care professionals operating within the scope of their licenses;
(ix) Repealed By Laws 1999, ch. 119, § 2.
(x) "Health care facility" means any ambulatory surgical center, assisted living facility, adult day care facility, adult foster care home, alternative eldercare home, birthing center, boarding home, freestanding diagnostic testing center, home health agency, hospice, hospital, freestanding emergency center, intermediate care facility for people with intellectual disability, medical assistance facility, nursing care facility, rehabilitation facility and renal dialysis center;
(xi) "Home health agency" means an agency primarily engaged in arranging and directly providing nursing or other health care services to persons at their residence;
(xii) "Hospice" means a program of care for the terminally ill and their families given in a home or health facility which provides medical, palliative, psychological, spiritual and supportive care and treatment. Hospice care may include short term respite care for non hospice patients, if the primary activity of the hospice is the provision of hospice services to terminally ill individuals and provided that the respite care is paid by the patient or by a private third party payor and not through any governmental third party payment program;
(xiii) "Hospital" means an institution or a unit in an institution providing one (1) or more of the following to patients by or under the supervision of an organized medical staff:
(A) Diagnostic and therapeutic services for medical diagnosis, treatment and care of injured, disabled or sick persons;
(B) Rehabilitation services for the rehabilitation of injured, disabled or sick persons;
(C) Acute care;
(D) Psychiatric care;
(E) Swing beds.
(xiv) "Intermediate care facility for people with intellectual disability" means a facility which provides on a regular basis health related care and training to persons with intellectual disabilities or persons with related conditions, who do not require the degree of care and treatment of a hospital or nursing facility and services above the need of a boarding home. The term also means "intermediate care facility for the mentally retarded" or "ICFMR" or "ICFs/MR" as those terms are used in federal law and in other laws, rules and regulations;
(xv) "Medical assistance facility" means a facility which provides inpatient care to ill or injured persons prior to their transportation to a hospital or provides inpatient care to persons needing that care for a period of no longer than sixty (60) hours and is located more than thirty (30) miles from the nearest Wyoming hospital;
(xvi) "Nursing care facility" means a facility providing assisted living care, nursing care, rehabilitative and other related services;
(xvii) "Physician" means a doctor of medicine or osteopathy licensed to practice medicine or surgery under state law;
(xviii) "Psychiatric care" means the in patient care and treatment of persons with a mental diagnosis;
(xix) "Rehabilitation facility" means an outpatient or residential facility which is operated for the primary purpose of assisting the rehabilitation of disabled persons including persons with acquired brain injury by providing comprehensive medical evaluations and services, psychological and social services, or vocational evaluations and training or any combination of these services and in which the major portion of the services is furnished within the facility;
(xx) "Renal dialysis center" means a freestanding facility for treatment of kidney diseases;
(xxi) "Swing bed" means a special designation for a hospital which has a program to provide specialized in patient long term care. Any medical surgical bed in a hospital can be designated as a swing bed;
(xxii) "Assisted living facility" means a dwelling operated by any person, firm or corporation engaged in providing limited nursing care, personal care and boarding home care, but not habilitative care, for persons not related to the owner of the facility. This definition may include facilities with secured units and facilities dedicated to the special care and services for people with Alzheimer's disease or other dementia conditions;
(xxiii) "Adult day care facility" means any facility not otherwise certified by the department of health, engaged in the business of providing activities of daily living support and supervision services programming based on a social model, to four (4) or more persons eighteen (18) years of age or older with physical or mental disabilities;
(xxiv) "Adult foster care home" means a home where care is provided for up to five (5) adults who are not related to the provider by blood, marriage or adoption, except in special circumstances, in need of long term care in a home like atmosphere. "Adult foster care home" does not include any residential facility otherwise licensed or funded by the state of Wyoming. The homes shall be regulated in accordance with this act and with the Wyoming Long Term Care Choices Act, which shall govern in case of conflict with this act;
(xxv) "Alternative eldercare home" means a facility as defined in W.S. 42 6 102(a)(iii). The homes shall be regulated in accordance with this act and with the Wyoming Long Term Care Choices Act which shall govern in case of conflict with this act;
(xxvi) "Freestanding emergency center" means a facility that provides services twenty four (24) hours a day, seven (7) days a week for life threatening emergency medical conditions and is at a location separate from a hospital;
(xxvii) "This act" means W.S. 35 2 901 through 35 2 913.
(b) This act does not apply to hospitals or any other facility or agency operated by the federal government which would otherwise be required to be licensed under this act or to any person providing health care services within the scope of his license in a private office.
35 2 902. License required.
No person shall establish any health care facility in this state without a valid license issued pursuant to this act.
ATTESTATION FORM
Ancillary or locations not within the
main building of the parent location
(Complete one for each additional location.)
LICENSED PROVIDER FACILITY NAME:
This is the same name as listed in number 1 of the license application form.
Ancillary Location Name:
Attach a copy of the organization chart that identifies where this ancillary location fits into your organization.
Ancillary Location Address (Be specific: Identify suite #, etc.):
# of Highway Miles from Main Building:
# of Radius Miles from Main Building:
List all the services being provided at this ancillary location by the provider listed in #1:
Are the employees at this ancillary location employees of the provider listed in #1?
YES NO
Are these employees under the supervision of another employee of the provider listed in #1?
YES NO
Are these services under the supervision of the organized medical staff of the provider listed in #1?
YES NO
How are referrals made to this location?
Are the services listed in #6 billed as a service to the Medicare/Medicaid CMS Certification Number (CCN) of
the provider listed in #1?
YES NO
If No, are these services billed under a private clinic, physician/specialists, or some other group
provider number?
YES NO
Name of Person Completing this form:
Title:
License Application Instructions
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