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.
Abortion Facilities:
Medical Care Facilities: (Hospitals & Ambulatory Surgical Centers) and Hospital Long Term Care Units: (Regulated by the Kansas Department of Health and Environment)
Application Forms:
- Application and Instructions for Medical Care Facility License
- Application and Instructions for Home Health Agency License **for an Initial Application Packet call (785) 296-1258** or request by email to lwilkins@kdheks.gov.
- Statement of Attestation for Home Health Agency License
Ambulatory Surgery Center (ASC) Survey Forms:
- ASC Licensure / Risk Management Survey Report
- Statement of Deficiencies and Plan of Correction Instructions - Health
- Interviews for ASC's
- Surgical and Anesthesia Records
- ASC Entrance Checklist
- ASC Surveyors Worksheet
- Infection Control Surveyor Worksheet
- Appendix L, Interpretive Guidelines for Ambulatory Surgical Centers
Change/Complaint 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.” http://www.aging.ks.gov/Default.html
- 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.” http://www.aging.ks.gov/Default.html
- Facility Complaint Investigation Report Form (for KDHE regulated facilities)
Critical Access Hospital Survey Forms:
- Hospital Restraint/Seclusion Death Report Worksheet - Long Form
- Hospital Restraint/Seclusion Death Report Worksheet - Short Form
- Hospital/CAH Medicare Database Worksheet
- Critical Access Hospital Procedures
- CAH Entrance Conference Information Sheet
- CAH Infection Control Worksheet
- CAH Licensure/Risk Management Survey Report
- CAH Medical Record Review Worksheet
- CAH Medical Staff Credentialing Personnel Record - Page 1
- CAH Medical Staff Credentialing Personnel Record - Page 2
- CAH Patient Interview Worksheet
- CAH Voluntary Self Review (.xls)
- CAH Appendix W - Survey Protocol, Regulations and Interpretive Guidelines for Critical Access Hospitals and Swing-Beds
- Statement of Deficiencies and Plan of Correction Instructions - Health
General Hospital and Special Hospital Survey Forms:
- Guidelines for the Operation of a Freestanding Emergency Department
- Hospital Restraint/Seclusion Death Report Worksheet - Long Form
- Hospital Restraint/Seclusion Death Report Worksheet - Short Form
- Hospital-Appendix A - Survey Protocol
- Hospital/CAH Medicare Database Worksheet
- Infection Control Worksheet for Hospitals
- Requested Hospital and Medical Staff Documents and Reports
- Entrance Conference Information Sheet
- Licensure/Risk Management Survey Report
- Medical Record Review Worksheet
- Medical Staff Credentialing Personnel Record - Page 1
- Medical Staff Credentialing Personnel Record - Page 2
- Patient Interview Worksheet
- Statement of Deficiencies and Plan of Correction Instructions - Health
Statement of Deficiency/Plan of Correction Forms and Instructions:
- Statement of Deficiency Instructions for State Agencies
- Instruction Pamphlet
- POC Instructions for Providers & Suppliers
- Providers POC Form
- Sample POC
Risk Management Forms:
- Quarterly Report Form
- Instructions for Quarterly Report Form
- Risk Management Incident Report Form
- Risk Management Standard of Care Interpretive Guidelines
- Risk Management Mailbag
- Risk Management Regulations with Surveyor Guidance
- Sample Risk Management Plan
- Risk Management Plan Review Tool
- Risk Management Annual Reports
- Risk Management Training Slides
- Statement of Deficiencies and Plan of Correction Instructions - Risk Management
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:
- Application and Instructions for Home Health Agency License
- Agency Complaint Investigation Report Form (NEW)
- HHA Licensing Decision Tree
- Regulation Interpretation
- Statement of Deficiencies and Plan of Correction Instructions - Health
Medicare Certification Forms:
Use the following links to obtain information about Medicare fee-for-service provider/supplier enrollment.
OASIS Training:
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 ClinicMedicare Certification Forms:
Use the following links to obtain information about Medicare fee-for-service provider/supplier enrollment.