The BHCS LTC 125 form plays a critical role in the operations of long-term care facilities within Michigan, serving as the official certificate of appointment for authorized representatives within these establishments. Governed by the Michigan Department of Licensing and Regulatory Affairs Bureau of Health Care Services, this document essentially facilitates a smooth interaction between long-term care facilities and the governing body, ensuring compliance and streamlined communication. By appointing an authorized representative, a facility can efficiently submit applications, make necessary amendments, provide crucial information for application determinations, engage in agreements related to licensure or certification, and receive notices or services of process. This document, effective immediately upon the date of action, remains valid until a formal termination notice is sent to the Director of the Long Term Care Division. Furthermore, it underscores the state's commitment to non-discrimination and accessibility, aligning with principles set forth by the AMERICANS WITH DISABILITIES ACT, thereby ensuring that individuals of different races, sexes, religions, ages, national origins, colors, marital statuses, disabilities, or political beliefs have equal access and are fairly represented.
| Question | Answer |
|---|---|
| Form Name | Form Bhcs Ltc 125 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | licensure, remit, REGULATORY, 1978 |
MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS
BUREAU OF HEALTH CARE SERVICES
LONG TERM CARE DIVISION
CERTIFICATE OF APPOINTMENT FOR AUTHORIZED REPRESENTATIVE
Facility Name:
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Notice is hereby given to the Michigan Department of Licensing and Regulatory Affairs in |
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accordance with a provision of Rules for Nursing Homes that |
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__________________ |
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(Owner of facility requesting license and/or certification) |
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has appointed |
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as its authorized representative to: |
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(Name) |
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a.Submit applications and make amendments thereto.
b.Provide the Department with all information necessary for a determination with respect to applications.
c.Enter into agreements with the Department in connection with licensure or certification.
d.Receive notice and service of process in matters relating to licensure or certification.
This action taken on |
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and is effective immediately. |
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(Date) |
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This appointment will remain in effect until written notice of termination is sent to the Director, Long Term Care Division.
Signature of Owner |
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Witness:Date:
Witness:Date:
PLEASE REMIT TO:
Department of Licensing and Regulatory Affairs
Bureau of Health Care Services
Long Term Care Division
P.O. Box 30664
Lansing, MI 48909
The Michigan Department of Licensing and Regulatory Affairs will not |
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Completion: Voluntary |
discriminate against any individual or group because of race, sex, religion, |
Authority: P.A. 368 of 1978 as amended |
age, national origin, color, marital status, disability, or political beliefs. |
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You may make your needs known to this Agency under the AMERICANS WITH |
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DISABILITIES ACT if you need assistance with reading, writing, hearing, etc. |