Form Bcal 1600 PDF Details

Assisting individuals and companies in navigating the licensure process for homes for the aged in Michigan, the BCAL-1600 form serves as a critical first step. Provided by the Michigan Department of Human Services through its Bureau of Children and Adult Licensing, this comprehensive form guides applicants through the requirements for operating such a facility. It covers a wide array of essential information, starting from basic facility details to more complex information about ownership, management structures, and compliance attestations. Applicants are prompted to provide information on the type of application—be it for a new license, a change of ownership, or updates to existing information—alongside details about the facility itself, including its name, address, and the number of beds it plans to license. Moreover, it delves into specifics about the owners or operators' identities, their legal structure, and any individuals or companies holding an interest in both the operation and property. The form also mandates the appointment of an authorized representative and an administrator, ensuring there are designated contacts for regulatory matters. Lastly, it concludes with a certification section where applicants affirm their compliance with relevant laws and regulations, highlighting the seriousness and legal obligations entailed in running a home for the aged. Ensuring the accuracy and comprehensiveness of the information provided is essential, as any deficiencies could impede the licensing process, underlining the form's role not merely as paperwork but as a foundational element of responsible facility management and operation.

QuestionAnswer
Form NameForm Bcal 1600
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesaged application printable, bcal 1600 blank, bcal 1600 blank form, bcal 1600

Form Preview Example

HOMES FOR THE AGED

APPLICATION FOR LICENSURE

Michigan Department of Human Services Bureau of Children and Adult Licensing

FOR DHS USE ONLY – Cashier code: 41

License Number:

Paid Amount:

Cashier:

SECTION I - FACILITY INFORMATION

TYPE OF APPLICATION:

INITIAL: NEW CONSTRUCTION APPLICATION INFORMATION UPDATE

EXISTING BLDG NOT CURRENTLY LICENSED AS HFA

CHANGE OF OWNERSHIP

1. Facility Name

 

2. Main/Public Telephone No.

 

3. Fax Number

 

 

 

4. E-Mail address

 

 

 

(

)

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Facility Street Address

6. City/Village/Township

 

7. State

 

 

 

8. Zip Code

 

9. County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

Facility Mailing Address (if different than #5)

 

 

11. City

 

 

12. State

 

 

 

13. Zip Code

 

14. County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15.

Number of Beds to be Licensed

 

 

 

16. Administrative/Emergency Phone No.

 

17. Program

 

 

 

 

 

 

 

 

 

 

(

 

)

 

 

 

 

 

 

Aged

 

Dementia/Alzheimers

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION II – APPLICANT/LICENSEE INFORMATION

 

 

 

 

 

 

 

 

 

 

18.

Individual(s)/Company (that owns operation to be licensed)

 

 

 

 

 

19. Federal Tax I.D. Number or Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20.

Individual(s)/Company Street Address

 

 

 

21. Individual(s)/Company City

 

 

22. State

23. Zip Code

 

24. County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25.

Mailing Address (if different than #20)

 

 

 

26. City

 

 

 

 

27. State

28. Zip Code

 

29. County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

30. Individual(s)/Company Telephone

 

 

 

 

 

 

 

 

 

 

 

31. Fax Number

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

(

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

32.

Type of ownership:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual(s)

Sole Proprietorship

 

Partnership

 

Limited Partnership

 

 

Limited Liability Partnership

 

 

LLC

Corporation

 

 

Non-Profit

 

Government

 

 

Other (specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION III – CORPORATION OFFICERS/DIRECTORS/TRUSTEES/LLC MEMBERS OF #18 (if applicable)

(Attach additional pages if necessary)

NAME

TITLE

ADDRESS (City, State, Zip Code)

SECTION IV – LIST ALL PERSONS OR COMPANIES WITH OWNERSHIP INTEREST

(Attach additional pages if necessary)

NAME

ADDRESS (CITY, STATE, ZIP CODE)

OWNERSHIP IN OPERATION

OWNERSHIP IN PROPERTY

 

 

 

YES

NO

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

YES

NO

BCAL-1600 (Rev. 1-14) Previous edition obsolete. MS Word

1

SECTION V – LIST ANY PERSON OR COMPANY INVOLVED WITH THE OPERATION OF THE HOME THROUGH MANAGEMENT AGREEMENT (IF APPLICABLE)

NAME

ADDRESS (City, State, Zip Code)

SECTION VI – AUTHORIZED REPRESENTATIVE

An authorized representative shall be appointed and have and agree to the following authorities relative to licensure: submit applications and amendments, provide all requested information to the department, enter into agreements with the department, receive notice and service in matters relating to licensure. Use BCAL-1603 to notify the department of a subsequent change in the authorized representative.

33.

Authorized Representative

34.

Social Security #

35. Phone

 

 

 

 

(

)

 

 

 

 

 

36.

E-mail Address

37.

Alternative Phone Number

38. Fax Number

( )

( )

SECTION VII – ADMINISTRATOR Use BCAL-1606 to notify the department of a subsequent appointment or change in the administrator.

39.

Name of Administrator (if known)

40.

Social Security #

41. Phone

 

 

 

 

(

)

 

 

 

 

 

42.

E-mail Address

43.

Alternative Phone Number

44. Fax Number

( )

( )

SECTION VIII – CERTIFICATION AND SIGNATURES

The applicant certifies that he/she has read 1978 PA 368, and the Administrative Rules (325.1901 through 325.1981) regulating the operation of Homes for the Aged facilities. If granted a license, I will comply with the Act and these Rules.

Failure to submit accurate and complete information in a timely manner may result in denial of licensure. An applicant who makes a false statement in this application is subject to criminal penalties under Section 20142(5) of the Public Health Code (1978 PA 368).

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, in compliance with the Administrative Rule 325.1913(2), notification within 5 business days will be given to the Department for any changes to the information submitted on or with this application.

45. Individual Applicant or Member of the Applicant Company or Board (Print or Type)

46.Applicant/Member Phone Number

( )

47. Applicant/Member Signature

48. Date

NOTE: The application may not be signed by the authorized representative unless also a member of the applicant company or board.

Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.

AUTHORITY:

1978 PA 368 of 1978

COMPLETION:

Mandatory

NON-COMPLETION:

License issuance will be denied.

BCAL-1600 (Rev. 1-14) Previous edition obsolete. MS Word

2

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It is actually an easy task to fill out the document adhering to this detailed tutorial! Here is what you want to do:

1. To get started, when filling in the aged application printable, start in the section that includes the next fields:

Writing segment 1 of bcal licensure

2. Your next part is to fill out these blanks: Number of Beds to be Licensed, AdministrativeEmergency Phone No, Program, Aged, DementiaAlzheimers, SECTION II APPLICANTLICENSEE, IndividualsCompany Street Address, Mailing Address if different than, IndividualsCompany Telephone, Type of ownership, IndividualsCompany City, City, Federal Tax ID Number or Social, State, and Zip Code.

Part number 2 for filling in bcal licensure

In terms of Mailing Address if different than and Aged, be sure you do everything correctly in this section. These two are surely the most important fields in the PDF.

3. Completing NAME, ADDRESS CITY STATE ZIP CODE, OWNERSHIP IN OPERATION NO NO NO NO, YES YES YES YES, OWNERSHIP IN PROPERTY, YES YES YES YES, NO NO NO NO, and BCAL Rev Previous edition is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

ADDRESS CITY STATE ZIP CODE, NAME, and OWNERSHIP IN OPERATION NO NO NO NO in bcal licensure

4. The next section requires your details in the subsequent areas: NAME, ADDRESS City State Zip Code, SECTION VI AUTHORIZED, An authorized representative shall, Authorized Representative, Email Address, Email Address, Social Security, Phone, Alternative Phone Number, Fax Number, Alternative Phone Number, Fax Number, SECTION VII ADMINISTRATOR Use, and Social Security. Just be sure you fill in all of the requested info to move further.

The way to complete bcal licensure stage 4

5. To finish your form, this particular section includes several additional fields. Completing Individual Applicant or Member of, ApplicantMember Phone Number, ApplicantMember Signature, Date, NOTE The application may not be, Department of Human Services DHS, AUTHORITY, PA of, COMPLETION, Mandatory, NONCOMPLETION, License issuance will be denied, and BCAL Rev Previous edition will finalize the process and you'll be done before you know it!

How to fill in bcal licensure part 5

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