Updated Plan Approval Application Forms for Health Care Facilities

Updated Plan Approval Applications for Plans Submitted to the Health Services Section

Date: March 10, 2000 -- DSL-BQA-00-026

To: Ambulatory Surgical Centers ASC - 04	Hospitals HOSP 14
Community Based Residential Facilities CBRF 12	Nursing Homes NH 15
End Stage Renal Dialysis Centers ESRD - 04	Facilities for the Developmentally Disabled FDD 11
Hospices HSPCE 11	Fire Protection Professionals
Professional Engineers	Registered Architects

From: Susan Schroeder, Director, Bureau of Quality Assurance

The Health Services Section recently updated two forms to be used when submitting health care facility plans for review. Below are the form names and numbers with guidance on when to use a specific form. Please begin using these forms immediately.

DSL-2333 PLAN APPROVAL APPLICATION (PDF, 128 KB)

Plans submitted for review by DHFS-Health Services Section using the following chapters:

Commerce Ch. 58/HFS 124, 132, 134
Hospital, Nursing Home/FDD, or any building attached to a Ch. 58 building
HFS Ch. 83 (if attached to a Ch. 58 bldg)
Community Based Residential Facility attached to a Hospital, Nursing Home/FDD
Advisory Review for Title 18 buildings. (NFPA LSC Ch. 12 – 6, 26)
Hospice, End Stage Dialysis Unit, Ambulatory Surgery Center, Medical Office Building

DSL-2496 FREE-STANDING CBRF PLAN APPROVAL APPLICATION (PDF, 50 KB)

Plan approval for HFS Ch. 83 if not attached to a Commerce Ch. 58 Building, Free-Standing Community Based Residential Facilities

The forms may be duplicated as needed. These forms will be available on the DHFS website in the future at www.dhfs.state.wi.us. Please do not hesitate to contact our office at (608) 243-2088 with any questions you may have.

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Wisconsin Department of Health Services

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Updated Plan Approval Applications for Plans Submitted to the Health Services Section