Bhcs Ltc 101 Form – Fill Out and Use This PDF

Not e: Failure to correctly complete this application in its entirety may delay the processing of your application. Questions regarding this application can be directed to the Long Term Care Division at (517) 241-4712.

Choose one:	I nitial License Application			Change of Ownership (CHOW) License
	Renewal Application
Facility I nformation
Facility Name/ D.B.A. (Doing Business As)				State Facility Number		CMS Certification (CCN) #
						23 -
Address		City			County		Zip Code
Phone Number			Fax Number
Primary Contact Person for Facility			Phone Number
Emergency Contact Person			Phone Number
MDS Assessment Contact Person			Phone Number

NPI # (s) (National Provider I dentifier) Please attach a separate sheet if necessary.

Licensed Administrator (submit a copy of your current license)

Administrator Name

E-mail Address

License Expiration Date

Date of Hire

License Number

4

8

Time I nvolvement:

Full-time

Part -time

Contract

I f the Licensed Administrator is not full time and he/ she is the licensed administrator at more than one facility indicate who will be in charge in the absence of the administrator.

I f the Licensed Administrator is part -time what is the name of the other facility he/ she will be working at?

Licensed Director of Nursing (submit a copy of your current license)

Director of Nursing Name

License Number

4

7

0

License Expiration Date

Date of Hire

Fiscal I ntermediary I f applying for Licensure & Certification this section must be completed.

Fiscal I ntermediary

I ntermediary/ Carrier Number (This is not the Provider # or CCN)

Address

City

State

Zip Code

Authority: Administrative Rules 325-20201 thru 325-	The Michigan Department of Licensing and Regulatory Affairs will not discriminate
20215	against any individual or group because of race, sex, religion, age, national origin,
Completion: Mandatory	color, marital status, disability, or political beliefs. You may make your needs
BHCS-LTC-101 (Rev. 07/ 13)	known to this Agency under the Americans with Disabilities Act if you need
Page 1 of 4	assistance with reading, writing, hearing, etc.

Michigan Department of Licensing and Regulatory Affairs

Bureau of Health Care Services

Long Term Care Division

Officers/ Directors/ Trustees: (attach additional pages if necessary)

Name	Phone Number

Are there any directors, officers, agents, or managing employees of the institution agency or organization who have

been convicted of a criminal offense?

No

Yes → I f “yes”, please attach an additional sheet describing the event .

Does anyone listed own or have an interest in other healthcare facilities (for example: sole proprietor, partner, member of a

partnership, board of directors)? No Yes → I f “yes”, please attach an additional sheet indicating name, address, city, state & zip code and interest of parent corporation.

I s the applicant facility chain affiliated?

Are any persons who have ownership interest required to file a beneficial ownership report pursuant to the Federal

Authority: Administrative Rules 325-20201 thru 325-	The Michigan Department of Licensing and Regulatory Affairs will not discriminate
20215	against any individual or group because of race, sex, religion, age, national origin,
Completion: Mandatory	color, marital status, disability, or political beliefs. You may make your needs
BHCS-LTC-101 (Rev. 07/ 13)	known to this Agency under the Americans with Disabilities Act if you need
Page 3 of 4	assistance with reading, writing, hearing, etc.

Michigan Department of Licensing and Regulatory Affairs

Bureau of Health Care Services

Long Term Care Division

Building Ow ner

Legal Owner of Building		Phone Number
Address	City		State	Zip Code
Lien Holder (if different from building owner)

Management Company (who is responsible for nursing home day to day operations, if different than applicant?)

Name of Company	Phone Number

PLEASE ONLY COMPLETE THE ESTI MATED MONTHLY REVENUES/ EXPENDI TURES AND PROVI DE THE LI ST OF SUPPLI ERS I F YOU ARE REQUESTI NG AN I NI TI AL LI CENSE FOR THE NURSI NG HOME OR I F YOU HAVE A CHANGE OF OW NERSHI P. NEI THER OF THESE TWO AREAS NEED TO BE COMPLETED I F THI S I S A RENEWAL APPLI CATI ON.

Estimated Monthly Revenues/ Expenditures:

Business experience related to nursing home operation, delivery of health care services:

Estimated monthly revenues:

Estimated monthly expenditures:

List of Suppliers

A list disclosing the names & addresses of each supplier who furnishes goods or services to the nursing home must be attached to this application. You must also include their total charges exceeding $5,000.00 in a 12 month period including a month in the nursing homes current fiscal year.

Certification of Applicant

The Assurance and processing of this form is governed by Administrative Rules 325.20201 through 325.20215. Failure to submit an accurate and complete form in a timely manner may result in denial of licensure or certification. An applicant who makes a false statement in this application is subject to criminal penalties under Section 20142(5) of the Public Health Code (P.A. 368 of 1978 as amended) including four years imprisonment and/ or $30,000 fine. Each facility must be brought in full regulatory compliance at the time a CHOW is approved.

The applicant certifies that the information provided on this application is true, complete and accurate to the best of his/ her knowledge.

The applicant certifies that the applicant and/ or owner(s) have not had a professional, occupational or health agency license revoked within the preceding five years.

Applicant’s Signature

Applicant’s Title

Date

For an I nitial License or Change of Ow nership request please submit the completed form to:

Michigan Department of Licensing and Regulatory Affairs/ BHCS/ Long Term Care Division

Ottawa Building, 1st Floor

P. O. Box 30664

Lansing, MI 48909

Authority: Administrative Rules 325-20201 thru 325-	The Michigan Department of Licensing and Regulatory Affairs will not discriminate
20215	against any individual or group because of race, sex, religion, age, national origin,
Completion: Mandatory	color, marital status, disability, or political beliefs. You may make your needs
BHCS-LTC-101 (Rev. 07/ 13)	known to this Agency under the Americans with Disabilities Act if you need
Page 4 of 4	assistance with reading, writing, hearing, etc.