Contact the individuals listed below to obtain the necessary Life Safety Code and Construction/Design approvals before returning the application. The Office of Fire Safety approval is required prior to granting a construction permit. The approval processes should be coordinated with these individuals:

     Larry Horvath, Certificate of Need Section
     Michigan Department of Community Health
     Bureau of Legal and Policy Affairs
     Lewis Cass Building, 3rd Floor
     320 South Walnut Street; Lansing, MI 48933
     Telephone: (517) 241-3344
and
     Jim Scott, Health Facilities Engineering Section
     Michigan Department of Community Health
     Bureau of Health Systems; Health Facilities & Services
     PO Box 30664; Lansing, MI 48909
     Telephone: (517) 241-3408
and
     Kim Osborn, Bureau of Fire Services
     Michigan Department of Energy, Labor & Economic Growth
     300 N. Washington Square, 4^th Floor
     PO Box 30700; Lansing, MI 48909
     Telephone: (517) 335-5804

The Hospital License Application (BHS-LC-100) form may be sent to the Division of Licensing & Certification by either faxing to 517-241-3354, e-mailing the attachment to dch-bhs-l&c@michigan.gov or by mailing it to the "Contact Information" address shown below. State licensure fees are $8.28 per bed and are billed biennially.

Complete and submit the Health Facility Information Sheet (BHS-LC-101) form using one of the preceding methods during renewal time each year.

Medicare Certification
The federal Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) contracts with the Department of Community Health, Bureau of Health Systems, to evaluate compliance with the federal hospital regulations by conducting surveys and complaint investigations. The hospital must be in compliance with the conditions and standards set forth in the Conditions of Participation for Hospitals (42 CFR, Part 482). There is no fee for certification.

The Medicare Provider/Supplier Enrollment Application (CMS-855A) must be submitted directly to the Fiscal Intermediary, National Government Services, LLC, for Medicare certification.

The other forms listed below must be submitted to the address shown under Contact Information.

-- One signed original of the Civil Rights Clearance for Medicare Provider Certification form

-- Two (2) signed originals of the Health Insurance Benefit Agreement (CMS-1561) form

-- One signed original of the Hospital/CAH Medicare Database Worksheet (Exhibit 286) form

Contact Information
      Michigan Department of Community Health
      Bureau of Health Systems; Division of Licensing & Certification
      P.O. Box 30664; Lansing, Michigan 48909
      Telephone: (517) 241-4160
      E-mail: dch-bhs-l&c@michigan.gov