Existing License Holder Four-Year Renewal Background Check Process

2008 Renewal:  The Division of Quality Assurance (DQA) is now conducting the required four year renewal of licensee background checks.  Entity license holders/legal representatives must comply with the requirements of DQA Memo 08-015 by June 30, 2008.  See the Frequently Asked Questions for more information.

DQA is required to complete caregiver background checks on license holders, board members and nonclient residents every 4 years or at any time within that period that the Department considers appropriate. When you receive notification from DQA, you must complete the 4 year renewal caregiver background check process.

As the license holder/legal representative, you should ensure that you, your board members (with client contact) and your nonclient residents (10 and older):

1. Complete a Background Information Disclosure (BID) form, F82064 (PDF, 30 KB).
2. Complete a Background Information Disclosure Appendix form, F82069 (PDF, 31 KB).
• If the license holder/legal representative owns multiple facilities, you may submit one BID and one BID Appendix if you indicate "see attached" on the BID Appendix, Section 3; and

• Attach a list of all DQA regulated facilities, including the Facility Name, Facility Address (Street, City, State, Zip Code), Facility license or certification number (if known) and facility type.

3. Include a $8.00 processing fee for each person, payable to the "Division of Quality Assurance." The processing fee is required unless you paid the fee to DQA as part of an initial application in 2008. If you are unsure if you meet this exemption, please include the fee. It will be returned to you if our records indicate it is not necessary.

4. Submit all forms with appropriate fee to:

Regardless of when you last submitted an application for licensure, certification or registration, you must submit the completed forms for the four-year renewal process.

Please only submit the forms and fee for the license holder/legal representative, board members and nonclient residents to DQA. Do not submit forms for your employees.

Pursuant to s. HFS 12.05, Wis. Admin. Code, an entity that violates any provision of background information gathering required by s. 50.065, Stats. may be subject to certain sanctions, including revocation, nonrenewal or suspension of regulatory approval.

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Last Revised: August 20, 2008