Hospitals: State Licensure and Medicare/Medicaid Certification

Include the following in your state licensure application:

• A letter of intent. This is a detailed statement of a proposed hospital facility. It must be written on official letterhead.
• A signed Hospital Certificate of Approval Application, F-62092.
• Hospital licensed bed fee ($18 per bed set by Wis. Stat. § 50.135(2)(a)). Make checks payable to the Division of Quality Assurance.
• Copies of contracts for all hospital services marked "2" or "3" on section H of the Hospital Certificate of Approval Application, F-62092.
• Proof that the hospital will be fully staffed when it opens. Fully staffed means staffed 24 hours a day, seven days a week. Provide information on:
  • Full-time RNs (registered nurses) and LPNs (licensed practical nurses). Include current registration or license numbers.
  • Active physician staff plans to ensure 24-hour coverage.
  • RN staff patterns.
• Facility floor plan.
• The resume and/or license information for the following people:
  • Hospital administrator/Chief executive officer
  • Substitute administrator/Chief executive officer
  • Medical director
  • Director of nursing
  • Medical record administrator or accredited record technician
  • Staff or consulting pharmacist
  • Registered dietician
  • Clinical Laboratory Improvement Amendment qualified lab director and certificate number
  • Medical social worker
• Patient rights and responsibilities policies (Wis. Stat. § 50.36(1))
• By-laws for the following:
  • Governing body (Wis. Stat. § 50.36(1))
  • Medical staff, including the various committees (Wis. Stat. § 50.36(1))
• Policies and rules for the following:
  • Quality assurance program
  • Nursing services
  • Medical record services
  • Physical environment
  • Infection control
  • Any service marked "1" or "3" on section H of the Hospital Certificate of Approval Application, F-62092
• Documents describing the type of hospital:
  • Corporation - Provide a copy of the articles of incorporation.
  • Limited liability company - Provide a copy of the articles of organization and operation agreement.
  • Limited liability partnership - Provide copies of the partnership agreement.
• Organizational chart. Identify other organizations connected to the applying hospital. This includes a parent company.
• Statements from each state licensing agency for applicants with facilities in other states. These statements should confirm the license status of each facility.
• A budget for the first 90 days after opening. This can be provided using a Model Balance Sheet, F-62674A (Word).
• Proof of financing for the first 90 days of hospital operation. This may include the following documents:
  • Statements for checking/savings accounts
  • Proof of stock, bond, or certificate of deposit ownership
  • Proof of outside employment and salary
  • Proof of income from another business
  • Credit reports
  • Letter(s) from financial institutions stating the extent of the applicant's line-of-credit and financial reference
• Lease agreements and management contracts, if applicable.
• Internal Revenue Service document showing employer identification number.
• Completed Background Checks Program. These are done online and cost $15 per person.
• Final approval of new construction. Plan Review approval is provided by the Office of Plan Review and Inspection. Contact the Office of Plan Review and Inspection to review your planned construction before it begins.

After submitting all documents, applications are sent to a nurse surveyor. They will review the application. If all standards are met, a state license will be issued.

Please allow for up to 90 days for review of your application.

Include the following in your Medicare licensure application:

• CMS-855 Medicare Enrollment Application. Contact your Medicare administrative contractor (MAC) for more information. You will submit this form directly to your MAC. Once the MAC has approved it, they will send a copy of the form along with their approval letter to the Wisconsin Department of Health Services (DHS).
• CMS-1572 Hospital Survey and Deficiencies Report from the Medicare certification survey. State agencies like DQA cannot complete this survey. Refer to CMS memo S&C-08-03 (PDF) for more information.
• CMS 1561 Health Insurance Benefits Agreement Form (PDF).
• A printout or screenshot of the confirmation page of the U.S. Department of Health & Human Services' Office of Civil Rights assurance of compliance attestation.

DQA reviews applications. They can recommend Medicare certification to CMS (Centers for Medicare & Medicaid Services). If approved by CMS, your hospital will receive a six-digit Medicare number that starts with "52." Medicare certification resources

• CMS Medicare Provider-Supplier Enrollment website
• 42 CFR 482, Code of Federal Regulations, Conditions of Participation for Hospitals