State ACH Licensure Forms


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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:

Change/Complaint Forms:

Critical Access Hospital Survey Forms:

General Hospital and Special Hospital Survey Forms:

Statement of Deficiency/Plan of Correction Forms and Instructions:

Risk Management Forms:

Medicare Certification Forms:

Use the following links to obtain information about  Medicare fee-for-service provider/supplier enrollment.

Home Health Agencies:

State Licensure/Complaint Forms:

Medicare Certification Forms:

Use the following links to obtain information about  Medicare fee-for-service provider/supplier enrollment.

OASIS Training:

Informal Review Process (IDR) for Certified Home Health Agencies

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:

Use the following links to obtain information about  Medicare fee-for-service provider/supplier enrollment.