Hospital Certificate Of Approval
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18DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Quality Assurance
Chapter 50.35, 50.498, and 946.32, Wis. Stats.
F-62092 (Rev. 07/09)
FOR DQA OFFICE USE ONLY
COA Number
COA Fee
Caregiver Background Fee
Effective Date
HOSPITAL CERTIFICATE OF APPROVAL APPLICATION
TYPE OF APPLICATION
Initial
Change of Ownership
Hospitals are required to complete this form per Chapter 50.35, Wis. Stats. Failure to complete this form may result in non-
issuance of a hospital certificate of approval.
The personally identifiable information collected on this form will be used to determine licensure eligibility and for statistical
information and for no other purpose.
Collection of the applicant’s social security number (SSN) or federal employer identification number (FEIN) is required by Chapter
50.498, Wis. Stats. Failure to supply the number may result in denial of the application. The number will be disclosed only to the
Department of Revenue for use in collection of tax delinquencies.
Return the completed application to: Division of Quality Assurance
Bureau of Technology, Licensing and Education
PO Box 2969
Madison WI 53701-2969
Bureau of Technology, Licensing and Education
Questions about completion of this application may be directed to the
at 608-
266-7297.
I. GENERAL INFORMATION
A. HOSPITAL LOCATION
Name –Facility
Initial Begin Date (at present location)
Previous Hospital Name (if applicable)
Street (physical) Address
Mailing Address
City
County
State
Zip Code
Telephone Number
Fax Number
E-mail Address
B. CHANGE OF OWNERSHIP
List the previous owner’s name, Certificate of Approval (COA) number, and Medicare and Medicaid numbers.
Name – Previous Owner
Previous COA Number
Medicare Number - Previous Owner
Medicaid Number - Previous Owner
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