State ACH Licensure Forms


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News and Announcements

Effective 07/01/2017, the updated Home Health Agency Licensure application and information is available here. There are now two classes of HHA Licensure. Please read the information under Home Health Agencies below for more information.

Effective March 1, 2004 - All Adult Care Homes (including assisted living/residential health care facilities, boarding care homes, home plus facilities and adult day care) are now managed by Kansas Department for Aging and Disability Services
Licensure and Certification and Evaluation Commission
503 S. Kansas Ave
Topeka, KS 66603-3404
Phone: 785-296-4986

FORMS

This page makes available for direct download as Portable Document Format (.pdf) files (see note above) state licensure and related forms and instructions for health care providers regulated by the Health Facilities Program. Additionally this page provides links to Medicare certification forms and related information which may be applicable to health care providers seeking Medicare reimbursement. A general link to forms of the Centers for Medicare & Medicaid Services (formerly Health Care Financing Administration) is as follows: http://cms.hhs.gov/forms/ Links to specific provider/supplier enrollment forms and associated information can be found in the sections below. Please consult appropriate state laws and state regulations as well as federal laws and federal regulations for definitions and other requirements for the provider types discussed on this page. Questions about state licensure/Medicare certification forms for KDHE regulated providers can be directed to: Hospital and Medical Program at 785-296-0127.

Fee Payment

Submission of the Home Health Agency application state licensure form below also requires a fee. KDHE currently accepts only checks or money orders for these fees made payable to Health Facilities Program or KDHE.

Medical Care Facilities: (Hospitals & Ambulatory Surgical Centers) and Hospital Long Term Care Units: (Regulated by the Kansas Department of Health and Environment)

Application Forms:

Ambulatory Surgery Center (ASC) Survey Forms:

Birthing Centers

Change Forms:

  • Request to Change Use of a Required Room (for KDHE regulated long term care units of hospitals)
  • “These forms are available and processed through the Kansas Department for Aging and Disability Services (KDADS), please follow this link to obtain the forms and the KDADS contact.” https://www.kdads.ks.gov/
  • Request to Change Bed Capacity and/or Location (for KDHE regulated long term care units of hospitals)
  • “These forms are available and processed through the Kansas Department for Aging and Disability Services (KDADS), please follow this link to obtain the forms and the KDADS contact.” https://www.kdads.ks.gov/

Reporting Form for Abuse Neglect & Exploitation:

Critical Access Hospital Survey Forms:

General Hospital and Special Hospital Survey Forms:

Statement of Deficiency/Plan of Correction Forms and Instructions:

Medicare Certification Forms:

  • For Certification Forms and Information: Send Email Request to: Tamara.Wilkerson@ks.gov, Medicare Certification Coordinator

RISK MANAGEMENT KDHE MEDICAL CARE FACILITIES

Risk Management Reporting Forms:

Risk Management Education and Training:

Risk Management Newsletters

Risk Management Helpful Decision Tools:

Risk Management Annual Reports:

Risk Management Resources for Survey Preparation:

 

HOME HEALTH AGENCIES

Kansas Statutes and Regulations for State Home Health Agency Licensure

Application for State Home Health Agency Licensure

Reporting Form for Abuse Neglect & Exploitation

Medicare Certification for Home Health Agencies

  • For Certification Forms and Information: Send Email Request to: Tamara.Wilkerson@ks.gov, Medicare Certification Coordinator

Education and Training for OASIS (Typically Certified Only)

Informal Review Process (IDR) for Certified Home Health Agencies

Miscellaneous Home Health or Home Care Resources

Other Provider Types Regulated by BHF that do not Require State Licensure:

Comprehensive Outpatient Rehabilitation Facility  
End Stage Renal Disease (Dialysis) Facilities
Hospice
Outpatient Provider of Physical Therapy/Occupational Therapy/Speech Pathology Services
Portable X-ray Facility
Rural Health Clinic

Medicare Certification Forms:

  • For Certification Forms and Information: Send Email Request to: Tamara.Wilkerson@ks.gov, Medicare Certification Coordinator