Wisconsin My Choice Family Care Adult Family Home Application
This file is an application form for My Choice Family Care Adult Family Home re-certification. It meets Wisconsin Medicaid standards for certified 1-2 bed Adult Family Homes. Completing and submitting the form is necessary for certification and operation.
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How do I fill this out?
To fill out this form, ensure you complete all required fields and attach the necessary documents. Provide the completed form to My Choice AFH Certifier with copies of all items listed in red during their site inspection. Any applicable recertification fee must be included.
How to fill out the Wisconsin My Choice Family Care Adult Family Home Application?
1
Complete all required fields in the form.
2
Attach necessary documents as listed in red.
3
Submit the completed form to My Choice AFH Certifier.
4
Include any applicable recertification fee.
5
Ensure all information is accurate and up-to-date.
Who needs the Wisconsin My Choice Family Care Adult Family Home Application?
1
Adult family home operators for re-certification.
2
Wisconsin Medicaid providers meeting certification standards.
3
Individuals responsible for operating 1-2 bed adult family homes.
4
Persons needing to update certification with current information.
5
Any adult family home operator required to comply with state regulations.
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What are the instructions for submitting this form?
Complete all required fields in the form and attach the necessary documents listed in red. Submit the completed form to My Choice AFH Certifier via mail, email, or fax along with any applicable recertification fee. For further assistance, contact My Choice Wisconsin Provider Quality at 414-287-7600.
What are the important dates for this form in 2024 and 2025?
Please check the official website or contact My Choice Wisconsin for the specific application deadlines for 2024 and 2025.
What is the purpose of this form?
The purpose of this form is to facilitate the re-certification process for Adult Family Homes under Wisconsin Medicaid standards. By completing and submitting this form along with the required documents, operators demonstrate compliance with state regulations. This form ensures that the adult family home is thoroughly inspected and verified to provide safe and adequate care for residents.
Tell me about this form and its components and fields line-by-line.
- 1. Operator Information: Includes fields for name, address, telephone number, facility name, and other contact information.
- 2. Non-Resident Information: Requires details of any non-residents living in the adult family home.
- 3. Staff Information: Information on staff members assisting at the adult family home, including names, dates of birth, and roles.
- 4. Home Details: Questions about the home, such as type of home, resident capacity, and accessibility features.
- 5. Pets: Information about any pets in the home and their vaccination status.
- 6. Safety Compliance: Fields related to fire extinguishers, smoke detectors, fire drills, and carbon monoxide detectors.
What happens if I fail to submit this form?
Failure to submit this form on time may result in delays or loss of certification.
- Delay in Processing: Failure to submit on time could cause significant delays in the processing of your certification.
- Loss of Certification: An incomplete or late submission may lead to a temporary or permanent loss of certification status.
How do I know when to use this form?
- 1. Re-Certification: When your current certification is due to expire and needs renewal.
- 2. Information Update: When there are changes to the home’s operator or other critical information.
Frequently Asked Question
How do I fill out this form?
Complete all required fields and attach necessary documents. Submit the form to My Choice AFH Certifier with any applicable fees.
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Use PrintFriendly's e-signature tool to add your signature directly to the document.
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What documents do I need to attach?
Attach copies of medical exam, TB skin test, background disclosure forms, and other items listed in red.
Is there a fee for re-certification?
Yes, any applicable recertification fee must be included with your application.
How often do I need to get my fire extinguishers inspected?
Fire extinguishers must be inspected every year by an authorized dealer or local fire department.
What happens if I don't submit the form on time?
Failure to submit the form on time may result in delays or loss of certification.
Is my personal information secure?
Yes, all provided information is used for certification purposes in compliance with privacy laws.
Do I need to attach proof of pet vaccinations?
Yes, if you have pets, you must attach a copy of their current rabies vaccination records.
