The IRS has released a new form, Form F 00302, which can be used by employers to report their employees' health coverage. The form is designed to help the IRS keep track of individuals who are covered under employer-provided health plans. It is important to note that the form must be filed annually, and that it is only for employers with 50 or more employees. For more information on Form F 00302 and how to file it, please contact our office. We would be happy to answer any questions you may have. Thank you for your time.
| Question | Answer |
|---|---|
| Form Name | Form F 00302 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | DHS, wisconsin dhs form f00302, explanatory, Wis |
DEPARTMENT OF HEALTH SERVICES |
STATE OF WISCONSIN |
Division of Quality Assurance |
DHS 75.13, Wis. Admin. Code |
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COMMUNITY SUBSTANCE ABUSE SERVICES (CSAS)
OUTPATIENT CLINIC RECERTIFICATION APPLICATION
DHS 75.13 Outpatient Treatment Service
▪This form accompanies DQA form
▪Applicants affirm compliance with each “YES” answer. A response of “NO” indicates likely
▪Attach additional narrative or plans for improvement for every “NO” answer.
▪To provide the opportunity to begin
Name - Facility
Certification Number
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Address – Physical |
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Mailing Address (if different from above) |
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Telephone Number |
Do not publish in Provider Directory. |
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Fax Number |
Internet Address |
Do not publish in Provider Directory. |
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Name - Contact Person |
Telephone Number |
Do not publish in Provider Directory. |
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YES |
NO |
1. |
DHS 75.13 (1) Service Description |
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This outpatient service is equivalent to the service description in DHS 75. |
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YES |
NO |
2. |
DHS 75.13 (2) General Requirements |
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This service is operated at the location described in the 75.03 application. |
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YES |
NO |
3. |
DHS 75.13 (3) Required Personnel |
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This service has personnel arrangements sufficient to meet its functional responsibilities. |
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YES |
NO |
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1. |
Service director |
YES |
NO |
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2. |
Physician, medical supervision |
YES |
NO |
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3. |
Substance abuse counselors |
YES |
NO |
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4. |
Mental health professional |
YES |
NO |
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5. |
Clinical supervisor |
YES |
NO |
4. |
DHS 75.13 (4) Clinical Supervision |
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Clinical supervision is provided to clinical substance abuse counselors at a rate not less than 30 minutes for |
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every 40 hours of counseling rendered. |
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Clinical supervision is provided to other |
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40 hours of counseling rendered. |
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Supervision and evaluation is provided in core functions. |
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YES |
NO |
5. |
DHS 75.13 (5) Service Operations |
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This service meets all required service operations (a – e). |
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(a) Help with access to health services is a part of this service. |
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(b) A patient’s treatment plan is completed within two (2) visits after admission. |
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(c) Psychological tests are ordered as needed. |
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(d) |
Treatment plans are regularly reviewed as a part of ongoing assessment of the patient, and if dually |
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diagnosed, with a mental health professional. |
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(e) Medical director concurs by statement and signature with the diagnosis, level of care, assessment, |
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and treatment plan. |
YES |
NO |
6. |
DHS 75.13 (6) Admission |
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This service only admits to treatment those persons who are determined to be appropriate through the |
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application of WI- UPC or other approved placement criteria. |
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